A nurse is creating a plan of care for a client who has left-sided weakness following a stroke. Which of the following interventions should the nurse include in the plan?

Massage bony prominences on the client's left side.

Support the client's left arm on a pillow while sitting.

Position the bedside table on the client's left side.

Place the client's cane on their left side while ambulating.

Answer and Explanation

The Correct Answer is B

A is incorrect because massaging bony prominences on the client's left side can increase the risk of skin breakdown and pressure ulcers. The nurse should avoid applying pressure to areas with impaired circulation or sensation.

B is correct because supporting the client's left arm on a pillow while sitting can prevent edema, contractures, and nerve damage. The nurse should also encourage the client to perform active and passive range of motion exercises on their left arm.

C is incorrect because positioning the bedside table on the client's left side can discourage the client from using their right side, which can lead to neglect and learned nonuse. The nurse should position the bedside table on the client's right side and encourage them to reach for items with their right hand.

D is incorrect because placing the client's cane on their left side while ambulating can cause instability and falls. The nurse should place the cane on the client's right side and instruct them to move their left leg and cane together, followed by their right leg.

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Correct Answer is B

Explanation

Urinary output is an important indicator of ﬂuid balance and kidney function. After delivery, a woman may experience increased urinary output due to the loss of excess ﬂuid that was retained during pregnancy and the diuretic eﬀect of oxytocin, which is released during breastfeeding. This is a normal and expected finding in the postpartum period.
However, increased urinary output may also be a sign of urinary retention, which is the inability to empty the bladder completely. Urinary retention can occur due to trauma to the bladder or urethra during delivery, swelling or hematoma of the perineum, epidural anesthesia, or decreased bladder sensation.Urinary retention can lead to complications such as infection, bladder distension, or postpartum hemorrhage.
Therefore, when a woman who delivered a normal newborn 24 hours ago reports that she seems to be urinating every hour or so, the practical nurse (PN) should measure the next voiding, then palpate the client's bladder. This will help to assess the amount and quality of urine and the presence or absence of bladder distension. A normal urine output is about 30 ml per hour, and a normal bladder should feel soft and empty after voiding. If the urine output is low or high, or if the bladder feels firm or full after voiding, the PN should report these findings to the primary healthcare provider for further evaluation and intervention.

Therefore, option B is the correct answer, while options A, C, and D are incorrect.

Option A is incorrect because catheterizing the client for residual urine volume is an invasive procedure that should only be done if indicated by the primary healthcare provider.

Option C is incorrect because evaluating for normal involution and massaging the fundus are related to uterine function, not urinary function.

Option D is incorrect because obtaining a specimen for urine culture and sensitivity is not necessary unless there are signs of infection, such as fever, dysuria, or foul-smelling urine.

A. Extremity pulse +3 B. Capillary refill 2 seconds C. Right extremity is warm to the touch D. Adolescent reports no numbness or tingling E. Adolescent reports pain as 2 on a scale of 0 to 10.

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

Explanation

Extremity pulse +3, Capillary refill 2 seconds, Right extremity is warm to the touch, Adolescent reports no numbness or tingling, Adolescent reports pain as 2 on a scale of 0 to 10.

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A nurse is creating a plan of care for a client who has left-sided weakness following a stroke. Which of the following interventions should the nurse include in the plan?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A woman who delivered a normal newborn 24 hours ago reports, "I seem to be urinating every hour or so. Is that OK?" Which action should the practical nurse (PN) implement?

Correct Answer is B

Explanation

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

Explanation

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