A nurse is planning care for a client who has hemiplegia. Which of the following interventions should the nurse include?

Instruct the client to sit on a rubber ring when seated in a chair.

Raise the head of the client's bed to a 90° angle.

Use moisturizing lotion while massaging the client's bony prominences.

Place pillows between the client's knees when in a side-lying position.

Answer and Explanation

The Correct Answer is D

A)   Instructing the client to sit on a rubber ring may provide comfort for those with hemorrhoids or perineal discomfort but is not directly related to managing hemiplegia.
B)   Raising the head of the client's bed to a 90° angle may be uncomfortable and may not address the specific needs related to hemiplegia.
C)   Using moisturizing lotion while massaging the client's bony prominences is important for skin integrity but does not directly address the positioning needs of a client with hemiplegia.
D)   Placing pillows between the client's knees when in a side-lying position helps maintain proper alignment, prevents pressure ulcers, and promotes comfort for the client with hemiplegia.

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Correct Answer is B

Explanation

A) Skin breakdown could occur due to the catheter bag lying in bed, but it is not the primary risk associated with the observations noted.
B) A kinked IV tubing can lead to stasis of fluids, which increases the risk of infection. Additionally, if the urinary catheter bag is not positioned below the level of the bladder, urine can reflux back into the bladder, which also increases the risk of infection.
C) Neurogenic bladder is a condition typically associated with nerve damage, not directly related to the position of the catheter bag or kinked tubing.
D) Phlebitis is inflammation of a vein, which would not be directly caused by the issues noted with the urinary catheter.

Correct Answer is ["Pain level","ECG results"]

Explanation

The client's pain level should be addressed first based on the principle of prioritizing interventions according to the client's immediate needs and potential severity of the condition. Chest pain, especially when radiating to the left arm, is a concerning symptom that can indicate myocardial ischemia or infarction. It is essential to promptly assess and manage the client's pain to provide relief and potentially mitigate further cardiac damage. In this scenario, the client rates the pain as 7 out of 10, indicating moderate to severe discomfort, which warrants immediate attention.

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A nurse is planning care for a client who has hemiplegia. Which of the following interventions should the nurse include?

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Naxlex Comprehensive Predictor Exams

A nurse is assessing a client who has a urinary catheter. The nurse notes the client's IV tubing is kinked and the urinary catheter bag is lying next to the client in bed. The nurse should identify that the client is at risk for which of the following conditions?

Correct Answer is B

Explanation

A nurse is admitting a client who reports tightness in their chest that radiates to left arm. Exhibits Complete the following sentence by using the lists of options. The nurse should first address the client's Select... followed by the client's Select...ECG results

Correct Answer is ["Pain level","ECG results"]

Explanation

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