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
Abduction pillow
Sheepskin heel pad
Footboard
The Correct Answer is D
A. Trochanter roll. This device is used to prevent external rotation of the hips, especially in clients who are immobile or lying supine. It does not support the feet or ankles and does not prevent plantar flexion.
B. Abduction pillow. An abduction pillow is placed between the legs to maintain proper hip alignment, particularly after hip surgery. It is not designed to prevent foot drop or plantar flexion contractures.
C. Sheepskin heel pad. This provides skin protection and pressure relief to prevent pressure ulcers on the heels. While useful for comfort and skin integrity, it does not keep the foot in a neutral position to prevent contractures.
D. Footboard. A footboard is placed at the foot of the bed to help maintain the foot in dorsiflexion, thereby preventing plantar flexion contractures (also known as foot drop). It supports proper alignment and is the most appropriate device for this purpose in clients with limited mobility.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. "I will hang a new bag of TPN and IV tubing every 24 hours." This is the correct action. TPN solutions are high in glucose and lipids, which create an ideal environment for bacterial growth. Changing the bag and tubing every 24 hours reduces the risk of infection and sepsis, especially in clients with central lines.
B. "I will obtain the client's weight every other day." Weight should be monitored daily in clients receiving TPN to assess for fluid status, nutritional progress, and potential complications like fluid overload or retention.
C. "I will monitor the client's blood glucose level every 8 hours." Clients receiving TPN require more frequent glucose monitoring, typically every 4 to 6 hours, especially when therapy is initiated, due to the high dextrose content that can cause hyperglycemia.
D. “I will increase the rate of the TPN infusion to ensure the correct amount is given." TPN infusion rates should never be adjusted independently by a nurse. Changes must be made only with a provider’s order, as improper rate adjustments can lead to electrolyte imbalances, hyperglycemia, or fluid overload.
Correct Answer is D
Explanation
A. Place an ice pack over the cast. While this can help reduce swelling and pain, it is a comfort measure, not the priority. Safety assessments must be completed first before implementing non-urgent interventions.
B. Position the casted extremity on a pillow. Elevation is important to reduce swelling, but it follows after ensuring that circulation to the extremity is intact and that there are no signs of vascular compromise.
C. Teach the client to keep the cast clean and dry. Education is essential for long-term cast care, but it is not the first action after cast application. Immediate post-procedural monitoring takes precedence.
D. Palpate the pulse distal to the cast. The nurse should first assess for adequate circulation by checking distal pulses. This helps identify early signs of complications like compartment syndrome or impaired blood flow, making it the highest priority.
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