A nurse is caring for a client who is immobile.
Which of the following interventions is appropriate to prevent contracture?

Align a trochanter wedge between the client’s legs.

Apply an orthotic to the client’s foot.

Place a towel roll under the client’s neck.

Position a pillow under the client’s knees.

Answer and Explanation

The Correct Answer is B

An orthotic is a device that supports or corrects the function of a body part. In this case, an orthotic can help prevent foot drop, which is a common contracture deformity in immobile patients. Foot drop occurs when the muscles that lift the foot become weak or paralyzed, causing the foot to hang down at the ankle. An orthotic can keep the foot in a neutral position and prevent shortening of the calf muscles and Achilles tendon.

Choice A is wrong because a trochanter wedge is used to prevent external rotation of the hip, not contracture. A trochanter wedge is a triangular-shaped pillow that is placed between the legs to keep them parallel and aligned.

Choice C is wrong because a towel roll under the neck is used to maintain proper cervical alignment, not contracture. A towel roll can prevent hyperextension of the neck and support the natural curve of the spine.

Choice D is wrong because a pillow under the knees can actually cause contracture of the knee joint by keeping it in a flexed position. A pillow under the knees can also reduce blood flow to the lower extremities and increase the risk of deep vein thrombosis.

Contracture is a permanent tightening of the muscles, tendons, skin, and surrounding tissues that causes the joints to shorten and stiffen.

Contracture can limit the range of motion and function of the affected body part. Contracture can be caused by inactivity, scarring, or diseases that affect the muscles or nerves. Prevention of contractures requires early diagnosis and initiation of physical medicine approaches such as passive range of motion exercises and splinting before contractures are present or while contractures are mild.

Contracture is a permanent tightening of the muscles, tendons, skin, and surrounding tissues that causes the joints to shorten and stiffen.

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Correct Answer is C

Explanation

The correct answer is **c. Applies suction for 15 seconds**.

**Choice A rationale:** Inserting the catheter without applying suction is a proper step in the suctioning process. This action does not require intervention by the staff nurse.

**Choice B rationale:** Waiting for 2 minutes between suctions is a standard practice to prevent damage to the trachea and to allow the client to recover from the suctioning process. This action is also appropriate and does not require intervention.

**Choice C rationale:** Applying suction for 15 seconds is too long and can cause damage to the trachea. The recommended duration for suctioning is typically 5-10 seconds. This action requires intervention by the staff nurse to correct the procedure and ensure the client's safety.

**Choice D rationale:** Encouraging the client to cough during suctioning is a proper step to help clear the trachea and promote effective suctioning. This action does not require intervention by the staff nurse.

In summary, the newly licensed nurse's action of applying suction for 15 seconds is the one that requires intervention by the staff nurse to correct the procedure and ensure the client's safety.

A. Potassium level. B. Temperature. C. WBC count. D. Breath sounds. E. Blood pressure.

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

Explanation

B, C, and D. These findings require follow-up because they indicate possible complications of chemotherapy, such as infection, low blood cell counts, and lung damage.

Choice B is correct because a temperature of 38.6° C (101.5° F) is a sign of fever, which can indicate an infection. Chemotherapy can weaken the immune system and make the client more prone to infections.

Choice C is correct because a WBC count of 3,800/mm3 is below the normal range of 5,000 to 10,000/mm3 and indicates leukopenia, a condition of low white blood cells. Chemotherapy can cause leukopenia by damaging the bone marrow where blood cells are produced.

Choice D is correct because crackles heard at the bases of the lungs are abnormal breath sounds that can indicate fluid accumulation or inflammation in the lungs. Chemotherapy can cause lung damage by affecting the cells that line the airways or by triggering an immune response.

Choice A is wrong because a potassium level of 3.6 mEq/L is within the normal range of 3.5 to 5 mEq/L and does not require follow-up.

Choice E is wrong because a blood pressure of 114/56 mm Hg is within the normal range of less than 120/80 mm Hg and does not require follow-up.

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A nurse is caring for a client who is immobile. Which of the following interventions is appropriate to prevent contracture?

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Explanation

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Explanation

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A nurse is caring for a client who is immobile.
Which of the following interventions is appropriate to prevent contracture?