A nurse is caring for a client who has impaired mobility. Which of the following support devices should the nurse plan to use to prevent the client from developing plantar flexion contractures?

Sheepskin heel pad

Footboard

Trochanter roll

Abduction pillow

Answer and Explanation

The Correct Answer is B

A.   A sheepskin heel pad is primarily used for pressure ulcer prevention, not for preventing plantar flexion contractures.
B.   A footboard helps maintain the feet in a dorsiflexed position, preventing plantar flexion contractures in clients with impaired mobility. This device provides support and alignment to the lower extremities.
C.   A trochanter roll is used to prevent external rotation of the hips and to maintain proper alignment. It is not specifically designed to prevent plantar flexion contractures.
D.   An abduction pillow is used to maintain hip alignment and prevent hip adduction. It is not designed to address plantar flexion contractures.

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Correct Answer is B

Explanation

A - Using a stiff toothbrush is not appropriate for oral care in immobile clients, as it can irritate or damage the gums and oral tissues. A soft-bristled toothbrush is recommended to ensure gentle cleaning.

B - Turning the client on his side is the correct action to prevent aspiration. This position allows fluids and saliva to drain from the mouth, reducing the risk of aspiration, which is critical for immobile clients.

C - Using the thumb and index finger to keep the client’s mouth open can lead to accidental injury. Instead, a padded tongue blade should be used to maintain the client’s mouth open safely during oral care.

D - Applying petroleum jelly to the lips should be avoided, as it is oil-based and can increase the risk of aspiration if inhaled. A water-based lubricant or lip balm should be used instead.

A. After palpating the abdomen B. Prior to percussing the abdomen C. Prior to inspecting the abdomen D. After assessing for kidney tenderness

Correct Answer is B

Explanation

A. After palpating the abdomen is not the ideal time to auscultate bowel sounds.
Palpation may stimulate bowel sounds and potentially give a false impression of their presence or absence.
B. Prior to percussing the abdomen is the correct sequence. Auscultation of bowel sounds should be done before any other abdominal assessment techniques, including percussion or palpation. This allows the nurse to accurately hear any existing bowel sounds without interference.
C. Prior to inspecting the abdomen is not the ideal time for auscultation. Inspection focuses on visual examination and assessment, which does not involve listening for bowel sounds.
D. After assessing for kidney tenderness is not the correct timing for auscultating bowel sounds. Assessing for kidney tenderness involves a different aspect of the physical examination and does not influence bowel sound assessment.

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A nurse is caring for a client who has impaired mobility. Which of the following support devices should the nurse plan to use to prevent the client from developing plantar flexion contractures?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is providing oral care for a client who is immobile. Which of the following actions should the nurse take?

Correct Answer is B

Explanation

A nurse is assessing a client's bowel sounds. At which of the following points in the assessment should the nurse auscultate the client's abdomen?

Correct Answer is B

Explanation

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