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 C
Explanation
Rationale:
A. Maintain bed elevation at 20°: To reduce the risk of aspiration, the head of the bed should be elevated to at least 30°–45° during and after enteral feedings. A 20° elevation is insufficient to prevent gastric reflux and aspiration.
B. Check for gastric residual every 12 hr: Gastric residuals should generally be checked every 4–6 hours for clients receiving continuous enteral feedings. Waiting 12 hours increases the risk of feeding intolerance or aspiration from undetected residual accumulation.
C. Flush the tubing with 30 mL of water every 4 hr: Routine flushing helps prevent tube occlusion and maintains patency. It also ensures that the client receives adequate hydration, especially with continuous feeding systems.
D. Place enough formula in the container to last 18 hr: Formula in an open system should not hang longer than 4 hours due to the risk of bacterial contamination. Adding 18 hours’ worth increases the chance of microbial growth and infection.
Correct Answer is B
Explanation
Rationale:
A. Attach a single-line administration set: A blood transfusion requires a Y-type tubing with a filter and two lines—one for the blood and one for normal saline—to allow flushing and compatibility. A single-line set is inadequate.
B. Prime the tubing with 0.9% sodium chloride: Only 0.9% sodium chloride (normal saline) should be used to prime blood tubing, as it is compatible with blood products and prevents clotting or hemolysis. Dextrose or other solutions can cause cell lysis.
C. Use an IV catheter that is at least 24-gauge: A 24-gauge catheter is too small for routine blood transfusions. A larger bore, such as 18- to 20-gauge, is recommended to reduce the risk of hemolysis and allow adequate flow.
D. Use tubing that does not have a filter in the drip chamber: Blood transfusion sets must include a filter (usually 170–260 microns) to trap clots and debris. Using tubing without a filter increases the risk of transfusion reactions.
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