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.
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Correct Answer is D
Explanation
Given the older client's history of heart failure and current diagnosis of influenza, it is important for the nurse to ensure that appropriate infection control measures are being followed while providing care. In this scenario, the nurse observes the UAP wearing a gown and gloves to assist the client with sitting up to eat lunch. The nurse should review the need for the UAP to wear a face mask while in close contact with the client. Influenza is spread through respiratory droplets, so wearing a face mask is an important infection control measure to prevent the spread of the virus.
Reminding the UAP to apply a fitted respirator mask before entering the client's room may not be necessary in this situation, as a regular face mask may be sufficient for preventing the spread of influenza.
Additionally, the nurse should instruct the UAP to notify the nurse of any changes in the client's respiratory status. This will allow the nurse to monitor the client's condition closely and intervene promptly if needed.
Assigning the UAP to provide care for another client and assuming full care of the client may not be necessary, as long as appropriate infection control measures are being followed.
Correct Answer is A
Explanation
A. Correct. A filter needle should be used to withdraw medication from an ampule to prevent drawing up any glass fragments into the syringe.
B. Using the same needle to draw up and inject the client is not recommended to prevent contamination.
C. Breaking the neck of the ampule toward the body is not a safe practice, as it can cause injury.
D. Ampules should be disposed of properly in a sharps container, not a regular trash can.
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