A nurse is caring for a client who has a spinal cord injury. Which of the following support devices should the nurse plan to use to prevent plantar flexion contractures?
Trochanter roll
Footboard
Sheepskin heel pad
Abduction pillow
The Correct Answer is B
Rationale:
A. Trochanter roll: A trochanter roll is used to prevent external rotation of the hips in clients who are immobile. It does not support the feet or ankles and therefore does not prevent plantar flexion contractures.
B. Footboard: A footboard helps maintain the foot in a dorsiflexed, neutral position by providing firm support against the soles. This prevents foot drop, a common plantar flexion contracture in clients with limited mobility.
C. Sheepskin heel pad: Sheepskin heel pads protect the heels from pressure ulcers by reducing friction and shear but do not maintain ankle alignment or prevent plantar flexion of the feet.
D. Abduction pillow: An abduction pillow is placed between the legs to maintain hip alignment after procedures like hip replacement. It offers no support to the feet and does not prevent plantar flexion.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Rationale:
A. Weigh the client before and after the procedure: Weighing the client helps to assess the volume of fluid removed and its immediate impact on the client’s body weight. This also assists in evaluating the effectiveness of the procedure and monitoring for fluid imbalances or complications.
B. Administer a low-volume hypertonic enema the night before the procedure: Enemas are not indicated for paracentesis, which involves the peritoneal cavity, not the bowel. Preparing the bowel is not necessary for this procedure and does not influence its safety or effectiveness.
C. Place the client in a side-lying position for the procedure: Paracentesis is typically performed with the client in a semi- to high-Fowler’s position. This position causes ascitic fluid to collect in the lower abdomen, making it more accessible and reducing the risk of organ puncture.
D. Ensure the client has a full bladder just prior to the procedure: The bladder should be emptied before paracentesis to reduce the risk of accidental puncture. A full bladder increases the chance of bladder injury during the needle insertion into the peritoneal cavity.
Correct Answer is B
Explanation
Rationale:
A. Ketorolac: Ketorolac is a nonsteroidal anti-inflammatory drug (NSAID) that can cause gastrointestinal irritation and increase the risk of bleeding, especially in clients with a history of peptic ulcer disease. It should be avoided in this population.
B. Acetaminophen: Acetaminophen is the safest option for relieving headache in clients with a history of peptic ulcers because it lacks the gastrointestinal side effects associated with NSAIDs. It provides effective pain relief without increasing ulcer risk.
C. Ibuprofen: Ibuprofen, another NSAID, also carries a high risk of gastric irritation and peptic ulcer exacerbation. Chronic or even short-term use can worsen ulcers and lead to GI bleeding.
D. Aspirin: Aspirin has strong antiplatelet effects and is highly ulcerogenic. It increases the risk of gastric mucosal damage and should be avoided in clients with known peptic ulcer disease.
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