A nurse is caring for a client who has a thoracic spine injury. Which of the following actions should the nurse take when turning the client?

Place a pillow under the client's knees when changing positions.

Use a sheet when repositioning the client onto his side.

Apply an immobilizing collar on the client prior to movement.

Instruct the client to keep his arms at his side when altering positions.

Answer and Explanation

The Correct Answer is B

Rationale:

A. Place a pillow under the client's knees when changing positions: Elevating the knees with a pillow may be appropriate for comfort, but in a client with a thoracic spine injury, this can alter spinal alignment and increase the risk of further injury. Maintaining proper spinal alignment during all movements is more important than knee elevation.

B. Use a sheet when repositioning the client onto his side: Using a sheet for logrolling or turning helps maintain spinal alignment and allows multiple caregivers to move the client safely as a unit. This technique minimizes rotation or flexion of the spine, which is critical in preventing further spinal cord injury in clients with thoracic spine trauma.

C. Apply an immobilizing collar on the client prior to movement: Cervical collars are used for cervical spine injuries, not thoracic spine injuries. Applying a collar would not stabilize the thoracic spine and could give a false sense of security while performing repositioning.

D. Instruct the client to keep his arms at his side when altering positions: The client may need to assist in turning if possible, and keeping the arms rigidly at the side is not necessary. Restricting arm movement does not ensure spinal safety and may limit the client’s ability to participate safely in repositioning.

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Correct Answer is ["A","C","D"]

Explanation

Rationale:

A. Check gastric residuals every 4 hr: Monitoring gastric residual volume every 4 hours helps assess tolerance to enteral feeding and reduces the risk of aspiration. High residuals may indicate delayed gastric emptying, requiring adjustment of the feeding regimen or provider notification.

B. Check placement of the feeding tube by x-ray once daily: X-ray is the gold standard for initial confirmation of tube placement, not for routine daily checks. Ongoing verification is typically done by assessing pH of gastric aspirate and observing for signs of misplacement, making daily x-rays unnecessary and impractical.

C. Maintain the head of the client's bed at a 30° angle or higher: Elevating the head of the bed reduces the risk of aspiration during continuous enteral feedings. Proper positioning is a key intervention to promote safety and prevent complications such as pneumonia.

D. Change the feeding container and tubing every 24 hr: Changing the feeding container and tubing every 24 hours helps prevent bacterial contamination and infection. This is a standard infection-control measure in enteral feeding care.

E. Ensure the formula is cold before administration: Formula should be at room temperature before administration. Cold formula can cause gastrointestinal discomfort, cramping, and nausea, so heating it to room temperature improves tolerance and safety.

A. Bradypnea B. Sedation C. Constipation D. Euphoria

Correct Answer is A

Explanation

Rationale:

A. Bradypnea: Respiratory depression is the most serious and potentially life-threatening adverse effect of morphine, especially after IV administration when onset is rapid. Bradypnea indicates a compromised airway and inadequate ventilation, making it the nurse’s priority for immediate assessment and intervention to prevent hypoxia and respiratory arrest.

B. Sedation: Sedation is a common effect of morphine and requires monitoring, but it is less immediately dangerous than respiratory depression. The nurse should assess the depth of sedation and level of consciousness while ensuring airway safety.

C. Constipation: Constipation is a common long-term side effect of opioids, but it is not an immediate threat to life. Preventive measures can be planned, but it does not take priority over acute respiratory compromise.

D. Euphoria: Euphoria may occur with opioid administration and is generally not harmful in the short term. While the nurse should monitor for behavioral changes or signs of misuse, it does not pose an immediate risk compared with respiratory depression.

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System	Findings
General	Adult child accompanying parent reports decline in client, expressing concern over memory and thought process, appetite, and self-care. Adult child states, "My sibling and I hired help at home for my parent. We thought that would help but it has not. I found the title to the car today, signed over to me."
Physical	Client makes poor eye contact, speaks in a monotone voice, and has a lack of facial expression. Client reports sleeping 7 hr a night and getting up "once or twice per night to go to the bathroom." Client reports not wanting to eat anymore. Client's child reports their parent has lost about 8 lb in the past month. Heart rate 68/min
Affect	Client says, "Why don't you just leave me? I am of no use."

Body System	Findings
Neurological	Reports that dizziness and palpitations started 2 months ago. Alert and oriented to person, place, and time
Cardiovascular	Pedal pulses +1 bilaterally, Pedal edema +1 bilaterally. Capillary refill time 5 seconds for all extremities. Reports no pain with palpation of thorax.
Respiratory	Fatigue and dyspnea with exertion started 1 week ago. Lungs clear to auscultation bilaterally
Vital Signs	Heart rate 105/min Respiratory rate 20/min Blood pressure 164/92 mm Hg Oxygen saturation 96% on room air

A nurse is caring for a client who has a thoracic spine injury. Which of the following actions should the nurse take when turning the client?

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Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who is receiving continuous enteral feedings. Which of the following actions should the nurse take? (Select all that apply)

Correct Answer is ["A","C","D"]

Explanation

A nurse is caring for a school-age child who is postoperative and received morphine via IV bolus for pain 10 min ago. Which of the following findings is the nurse's priority?

Correct Answer is A

Explanation

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