A nurse is caring for a client who is immobile. Which of the following interventions is appropriate to prevent contracture?
Place a towel roll under the client's neck.
Position a pillow under the client's knees.
Apply an orthotic to the client's foot.
Align a trochanter wedge between the client's legs.
The Correct Answer is C
A. Incorrect. Placing a towel roll under the client's neck is a preventive measure to maintain proper cervical alignment, but it does not specifically address contracture prevention.
B. Incorrect. This can promote flexion of the knees, which may actually contribute to knee flexion contractures over time. While it might be comfortable for the client, it's not a preventive measure against contractures.
C. Correct. Orthotics can help maintain proper alignment of the foot and ankle, preventing foot drop and other related contractures. They are designed to support joints and muscles, minimizing the risk of stiffness and contracture formation.
D. Incorrect. Aligning a trochanter wedge between the client's legs might help prevent external rotation of the hips but does not specifically address contracture prevention.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Incorrect. Suggesting finding alternative remedies through an online support group may not provide accurate or safe information.
B. Correct. This response acknowledges the client's interest and offers to provide guidance in selecting a safe alternative practitioner. It's important to ensure that any alternative therapies are safe and evidence-based.
C. Incorrect. While it's important to respect the client's personal beliefs, the nurse should also ensure that the chosen therapies are safe and effective.
D. Incorrect. Waiting for the provider to suggest alternative therapies may delay the client's access to safe and effective treatments.
Correct Answer is ["255"]
Explanation
Step 1: Calculate half the total volume. The total volume is 4,080 mL. So, half the total volume is 4,080 mL ÷ 2 = 2,040 mL.
Step 2: Calculate the rate to administer half the total volume in the first 8 hours. So, the rate is 2,040 mL ÷ 8 hr = 255 mL/hr.
Therefore, the nurse should set the IV infusion pump to deliver 255 mL/hr to administer half the total volume in the first 8 hr.
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