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.

Answer and Explanation

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.

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Correct Answer is B

Explanation

After inhaling deeply using an incentive spirometer, you should hold your breath for 3 to 5 seconds before exhaling.
Choice A is wrong because exhaling slowly through pursed lips is not an instruction for using an incentive spirometer.
Choice C is wrong because placing hands on the upper abdomen during inhalation is not an instruction for using an incentive spirometer.
Choice D is wrong because positioning the mouthpiece.5 cm (1 in) from the mouth is not an instruction for using an incentive spirometer.

A. Back pain. B. Bradycardia. C. Hypertension. D. Chills.

Correct Answer is A

Explanation

The correct answer is A. Back pain.

Choice A reason: Back pain during a blood transfusion is a classic symptom of a hemolytic transfusion reaction. This type of reaction occurs when the immune system attacks the transfused red blood cells, leading to their destruction. Back pain is considered a more specific and early sign of this reaction.

Choice B reason: Bradycardia, which is a slower than normal heart rate, is not typically associated with hemolytic transfusion reactions. The normal range for an adult’s resting heart rate is between 60 to 100 beats per minute. Bradycardia is usually considered when the heart rate is lower than 60 beats per minute in a resting adult. It can be a sign of a well-trained athlete or can occur as a result of certain medications or heart conditions, but it is not a recognized symptom of a hemolytic transfusion reaction.

Choice C reason: Hypertension, or high blood pressure, is also not a common symptom of a hemolytic transfusion reaction. Normal blood pressure ranges from 90/60 mmHg to 120/80 mmHg. Hypertension is typically defined as having a blood pressure higher than 130/80 mmHg. While hypertension can be a serious condition, it is not indicative of a hemolytic transfusion reaction.

Choice D reason: Chills are a symptom that can be associated with a hemolytic transfusion reaction, often occurring alongside fever and back pain. However, while chills can indicate a reaction, back pain is a more specific symptom that can help differentiate a hemolytic reaction from other types of transfusion reactions.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is teaching a client about the use of an incentive spirometer. Which of the following instructions should the nurse include in the teaching?

Correct Answer is B

Explanation

A nurse is monitoring a client who is receiving 2 units of packed RBCs. Which of the following manifestations indicates a hemolytic transfusion reaction?

Correct Answer is A

Explanation

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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?