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 C
Explanation
A. Incorrect. A residual of 65 mL may indicate delayed gastric emptying, but it alone does not directly correlate with an increased risk of aspiration unless it leads to significant overdistension or the client is unable to tolerate further feedings.
B. Incorrect. Sitting in high Fowler's position during feeding is actually a preventive measure against aspiration.
C. Correct. his factor increases the risk for aspiration. Clients with gastroesophageal reflux disease (GERD) are more prone to refluxing contents from the stomach into the esophagus, which can lead to aspiration, especially during or after feedings.
D. Incorrect. The osmolarity of the formula might affect tolerance but is not directly related to aspiration risk.
Correct Answer is ["A","C","E"]
Explanation
A. Urine culture: This will help identify the presence of any urinary tract infection (UTI) causing discomfort and burning during urination.
B. Ibuprofen 600 mg every 6 hr for mild to moderate pain: While ibuprofen can help with pain relief, it does not address the potential underlying urinary tract infection, so it's important to address the infection first.
C. Obtain provider prescription for phenazopyridine: Phenazopyridine is a urinary analgesic that can provide relief from the pain and discomfort associated with UTIs.
D. Vaginal culture: The client's symptoms are related to discomfort and burning upon urination, suggesting a urinary tract issue rather than a vaginal issue. Therefore, a vaginal culture may not be relevant in this context.
E. Obtain provider prescription for antibiotics: If a urinary tract infection is suspected based on the client's symptoms and urine culture results, antibiotics may be needed to treat the infection.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.