A nurse is contributing to the plan of care for a client who is at risk for developing foot drop due to immobility. Which of the following interventions should the nurse recommend to include in the plan?

Flex the client's feet using pillows.

Support the client's feet with foot boots.

Place a hand roll under the client's heels.

Remove ankle-foot orthotic devices at bedtime.

Answer and Explanation

The Correct Answer is B

The correct answer is choice B: "Support the client's feet with foot boots."

Choice A rationale:

Flexing the client's feet using pillows might not be sufficient to prevent foot drop. Foot drop is a condition where the client is unable to dorsiflex their foot, and using pillows alone may not provide adequate support to prevent this condition.

Choice B rationale:

Supporting the client's feet with foot boots is the most appropriate intervention to prevent foot drop due to immobility. Foot boots are specifically designed to hold the foot in a dorsiflexed position, preventing the calf muscles from tightening and causing foot drop.

Choice C rationale:

Placing a hand roll under the client's heels might offer some relief, but it's not the most effective intervention for preventing foot drop. Hand rolls are generally used to prevent footdrop by keeping the ankles in a neutral position, rather than solely supporting the heels.

Choice D rationale:

Removing ankle-foot orthotic devices at bedtime is not recommended if the client is at risk for developing foot drop. Ankle-foot orthotic devices are designed to provide continuous support to the feet and prevent muscle contractures. Removing them at bedtime could compromise the effectiveness of the intervention.

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Correct Answer is B

Explanation

The correct answer is choice B: A client who has measles.

Choice A rationale:

Airborne precautions are indicated for diseases that spread via small particles suspended in the air, such as droplets or dust particles that remain in the air for prolonged periods. Pneumonia is primarily spread through larger respiratory droplets and is not considered an airborne disease. Therefore, airborne precautions are not necessary for a client with pneumonia.

Choice B rationale:

Measles is a highly contagious airborne disease caused by the measles virus. It is transmitted through respiratory droplets and can remain in the air for an extended period. Initiating airborne precautions, such as wearing an N95 respirator mask and placing the client in a negative pressure isolation room, is crucial to prevent the spread of measles to healthcare workers and other patients.

Choice C rationale:

Pertussis (whooping cough) is primarily spread through respiratory droplets, similar to pneumonia. While it is a serious bacterial infection, it is not classified as an airborne disease. Thus, airborne precautions are not required for a client with pertussis.

Choice D rationale:

Methicillin-resistant Staphylococcus aureus (MRSA) is mainly spread through direct contact with contaminated surfaces or individuals. Airborne precautions are not necessary for MRSA, as it is not transmitted through the air. Standard precautions, including wearing gloves and gowns, are typically sufficient when caring for a client with MRSA.

A. Keep the side holes of the mask closed. B. Ensure the reservoir bag is inflated on expiration. C. Apply petroleum jelly to the client's nostrils. D. Attach a humidifier to the base of the flow meter.

Correct Answer is D

Explanation

The correct answer is **d. Attach a humidifier to the base of the flow meter**.

Choice A rationale:

Keeping the side holes of the mask closed would restrict airflow and prevent the client from receiving the prescribed oxygen concentration. This action would be unsafe and should not be taken.

Choice B rationale:

Ensuring the reservoir bag is inflated on expiration is not necessary for a simple face mask. The reservoir bag is typically used with other oxygen delivery devices, such as a non-rebreather mask, to provide a higher concentration of oxygen. This action is not appropriate for the given scenario.

Choice C rationale:

Applying petroleum jelly to the client's nostrils is not a recommended action. Petroleum jelly can potentially cause irritation and dryness, which could lead to discomfort for the client. This action is not necessary for the safe administration of oxygen.

Choice D rationale:

Attaching a humidifier to the base of the flow meter is the appropriate action to ensure client safety. Humidifying the oxygen can help prevent drying of the client's airway and make the oxygen more comfortable to breathe. This is a recommended step when administering high-flow oxygen via a simple face mask.

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A nurse is contributing to the plan of care for a client who is at risk for developing foot drop due to immobility. Which of the following interventions should the nurse recommend to include in the plan?

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