A nurse is planning care for a client who is immobile. Which of the following actions should the nurse include in the plan of care?

Use trochanter rolls beside the client's legs.

Logroll the client every 4 hr.

Place the client's arms at their side when turning them.

Cross the client's ankles when lying supine.

Answer and Explanation

The Correct Answer is A

A. Use trochanter rolls beside the client's legs:

Trochanter rolls are positioning devices placed alongside the thighs to prevent external rotation of the hips when a client is lying supine. This helps maintain proper alignment and prevents hip contractures, especially in clients who are immobile.

B. Logroll the client every 4 hr:

Logrolling is a technique used to turn a client with spinal precautions, such as after spinal surgery or injury. It involves turning the entire body as a unit to avoid twisting the spine. However, in a general plan of care for an immobile client, logrolling every 4 hours may not be necessary unless there are specific medical indications.

C. Place the client's arms at their side when turning them:

Placing the client's arms at their side may not be the most optimal positioning during turns, as it can contribute to joint contractures. The nurse should consider positioning the arms in a manner that maintains joint flexibility and prevents contractures.

D. Cross the client's ankles when lying supine:

Crossing the client's ankles when lying supine is not a recommended practice. It can lead to pressure on the lateral aspect of the knees and ankles, potentially causing discomfort and impairing circulation. It is important to maintain proper alignment and support for the client's lower extremities.

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

Explanation

Correct responses:

A. When preparing the medication dosage: Comparing the medication administration record with the medication label during preparation helps ensure the correct medication and dosage are being used.

B. Directly before administering the medication: This final check ensures that the medication being given matches the prescription and the right patient, minimizing the risk of errors.

D. When removing the medication from the medication drawer: This initial check ensures that the medication being retrieved is the correct one as per the medication administration record.

The other options are not directly related to verifying the medication administration record against the medication label:

C. When reconciling counts of controlled substances: This is important for ensuring accurate inventory but is not related to verifying medication administration.

E. At the end of the shift: This is not a time for verifying medication records and labels; it’s more related to end-of-shift documentation and handoff.

A. "You need to understand that you have very little time left." B. "I will contact your provider to discuss your options." C. "Enjoy the time you have and do the things you want to do." D. "Hospice care is the best thing for you at this time."

Correct Answer is B

Explanation

A. "You need to understand that you have very little time left":

This response is blunt and may be emotionally distressing for the client. It is essential to communicate with sensitivity and respect the client's autonomy. This option does not explore the available treatment options, which is important in this situation.

B. "I will contact your provider to discuss your options":

This is the correct answer. It demonstrates the nurse's commitment to the client's wishes by taking proactive steps to explore treatment options. Involving the healthcare provider in the discussion allows for a more informed decision-making process and ensures that the client's preferences are considered in the overall care plan

C. "Enjoy the time you have and do the things you want to do":

This response may come across as dismissive and does not directly address the client's expressed desire for more treatment. It is important to acknowledge the client's wishes and explore available options before discussing end-of-life activities.

D. "Hospice care is the best thing for you at this time":

While hospice care is an important consideration for individuals with terminal illnesses, it may not align with the client's current preference for more treatment. Introducing hospice care at this point without discussing treatment options may be premature.

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A nurse is planning care for a client who is immobile. Which of the following actions should the nurse include in the plan of care?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is preparing to administer medications to a client. At which of the following times should the nurse compare the medication administration record and the medication label? (Select all that apply.)

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

Explanation

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Correct Answer is B

Explanation

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