A nurse is planning care for a client who has left-sided hemiplegia following a stroke.
Which of the following actions should the nurse include in the plan of care?
Provide the client with a short-handled reacher.
Place a plate guard on the client's meal tray.
Remind the client to use a cane on his left side while ambulating.
Position the bedside table on the client's left side.
The Correct Answer is A
The nurse should provide the client with a short-handled teacher.
This can help the client to reach and grasp objects without having to overextend or strain their unaffected arm.
Choice B is also correct.
The nurse should place a plate guard on the client’s meal tray.
This can help prevent food from spilling off the plate and make it easier for the client to eat with one hand.
Choice C is wrong because reminding the client to use a cane on his left side while ambulating could be unsafe as the client’s left side is affected by hemiplegia.
Choice D is wrong because positioning the bedside table on the client’s left side could make it difficult for the client to reach items on the table.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
“Weight loss of.8 kg (4 Ib) in the past 24 hr.” Furosemide is a diuretic that decreases the pressure caused by excess fluid in the heart and lungs.
A weight loss of.8 kg (4 Ib) in the past 24 hr indicates that excess fluid is being removed from the body, which is a sign that the medication is effective.
Choice A is incorrect because adventitious breath sounds are a symptom of pulmonary edema, not an indication that the medication is effective.
Choice B is incorrect because furosemide has direct vasodilatory outcomes 2, which would decrease blood pressure, not elevate it.
Choice D is incorrect because there is no information found to support this statement.
Correct Answer is B
Explanation
The correct answer is choice B: Insert an NG tube.
Choice A rationale: Inserting an indwelling urinary catheter may be necessary for monitoring urine output in some cases, but in this situation, the priority is to insert an NG tube. This will help prevent aspiration during surgery due to the client's high blood alcohol level, which increases the risk of vomiting.
Choice B rationale: Inserting an NG tube is the priority action for the nurse because a high blood alcohol level increases the risk of vomiting and aspiration during surgery. An NG tube can help reduce this risk by keeping the stomach empty and minimizing the chance of aspiration.
Choice C rationale: Obtaining consent for surgery is important, but in emergency situations, consent may be implied, or a designated surrogate decision-maker may provide consent. It is not the priority action for the nurse in this scenario.
Choice D rationale: Applying antiembolic stockings is a preventive measure for deep vein thrombosis, but it is not the priority action in this case. Ensuring the client's safety during surgery, specifically by preventing aspiration, takes precedence due to the client's high blood alcohol level.
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