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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","B","E"]
Explanation
A. Providing oral care involves contact with mucous membranes and saliva, which may contain blood or other potentially infectious materials. Therefore, the nurse should wear gloves to protect themselves and the client from cross-contamination.
B. Emptying urine from an indwelling urine collection bag involves contact with urine, which may contain blood or other potentially infectious materials. Therefore, the nurse should wear gloves to protect themselves and the client from cross-contamination.
C. Placing oral medication tablets into a client's hand does not involve contact with blood or other potentially infectious materials. Therefore, the nurse does not need to wear
gloves for this task.
D. Delivering a food tray to a client who has AIDS does not involve contact with blood or other potentially infectious materials. Therefore, the nurse does not need to wear gloves for this task. However, the nurse should follow standard precautions and wash their hands before and after contact with any client.
E. Changing an ostomy pouch involves contact with feces, which may contain blood or other potentially infectious materials. Therefore, the nurse should wear gloves to protect themselves and the client from cross-contamination.
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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