A nurse is caring for a client who has right-sided paralysis following a cerebrovascular accident. Which of the following prescriptions should the nurse anticipate to prevent a plantar ﬂexion contracture of the aﬀected extremity?

Sequential compression device

Abduction splint.

Ankle-foot orthotic.

Continuous passive motion machine.

Answer and Explanation

The Correct Answer is C

An ankle-foot orthotic can help prevent a plantar ﬂexion contracture of the aﬀected extremity in a client who has right-sided paralysis following a cerebrovascular accident. This device can help maintain the foot and ankle in a neutral position and prevent the development of a contracture.

a. A sequential compression device is used to prevent deep vein thrombosis and is not specifically designed to prevent contractures.

b. An abduction splint is used to maintain the hip in a neutral position and is not specifically designed to prevent contractures of the foot and ankle.

d. A continuous passive motion machine is used to promote joint mobility and is not specifically designed to prevent contractures of the foot and ankle.

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Correct Answer is B

Explanation

The correct answer is that the nurse should include information about the eﬀectiveness of the last dose of pain medication in the hand-oﬀ report when transferring a client to a long-term care facility. This information is important for the receiving facility to continue managing the client's pain eﬀectively.

Options a, c and d are not essential information to include in the hand-oﬀ report. The time of the client's last bath, the number of family members who have visited and the frequency of previous vital sign measurement are not critical for ensuring continuity of care during the transfer.

A. Palpate the brachial pulse site. B. Discontinue palpation of the brachial pulse. C. Inﬂate the blood pressure cuﬀ to 30 mm Hg beyond where the brachial pulse was last felt. D. Deﬂate the blood pressure cuﬀ slowly until the brachial pulse is detected.

Correct Answer is A, C, B, D

Explanation

First, the nurse should palpate the brachial pulse site to locate the artery. Next, the nurse should inﬂate the blood pressure cuﬀ to 30 mm Hg beyond where the brachial pulse was last felt. The nurse should then discontinue palpation of the brachial pulse and deﬂate the blood pressure cuﬀ slowly until the brachial pulse is detected. This is the point at which the systolic blood pressure can be read.

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A nurse is caring for a client who has right-sided paralysis following a cerebrovascular accident. Which of the following prescriptions should the nurse anticipate to prevent a plantar ﬂexion contracture of the aﬀected extremity?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse in an acute care facility is preparing to transfer a client to a long-term care facility. Which of the following information should the nurse include in the hand-oﬀ report?

Correct Answer is B

Explanation

A nurse is preparing to palpate a client's systolic blood pressure using the brachial artery. After applying the blood pressure cuﬀ to the client's arm, identify the sequence of steps the nurse should follow. (Arrange the steps, placing them in the order of performance. Use all the steps.)

Correct Answer is A, C, B, D

Explanation

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