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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
The nurse should provide written materials in the client's primary language for a client who requires teaching prior to discharge. This ensures that the client has access to important information in a language they understand and can refer to after leaving the facility.
b. A client who is watching a video about meal services in their primary language may not require additional written materials.
c. A client who is learning to use an incentive spirometer with the help of an interpreter may not require additional written materials.
d. The administration of a prescribed pain medication does not necessarily require the provision of written materials.
Correct Answer is B
Explanation
Before administering enteral feedings via an NG tube, the nurse should check for gastric residual volume to ensure that the client is able to tolerate the feeding. If the residual volume is high, it may indicate delayed gastric emptying and the feeding may need to be delayed or the rate adjusted.
a. Encouraging the client to take sips of water may help maintain hydration, but it is not necessary prior to administering enteral feedings.
c. Flushing the tube with sterile 0.9% sodium chloride irrigation can help maintain patency of the tube, but it is not necessary prior to administering enteral feedings.
d. Encouraging the client to breathe deeply and cough can help clear secretions from the lungs, but it is not necessary prior to administering enteral feedings.
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