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 C

Explanation

A. Request that another nurse check the client's BP in 30 min:

Waiting for 30 minutes to have another nurse check the blood pressure may not be the most immediate and effective action. If there are concerns about the accuracy of the reading, rechecking the BP in the other arm promptly is a more appropriate and efficient approach.

B. Reposition the client supine and recheck her BP:

Repositioning the client supine is not necessary in this context. Blood pressure can be accurately measured while the client is sitting. Changing the position might not provide relevant information about the accuracy of the blood pressure reading.

C. Recheck the client's BP in her other arm for comparison:

This is the appropriate action. Checking the blood pressure in the other arm can help determine if there is a significant difference between the arms. A significant difference could indicate arterial disease or other issues. It's essential to confirm the accuracy of the blood pressure measurement.

D. Ensure that the width of the BP cuff is 50% of the client's upper arm circumference:

While ensuring the appropriate size of the BP cuff is essential for accurate readings, this option is not directly addressing the current situation of an elevated blood pressure reading. Checking the other arm for comparison is more relevant to assess the accuracy of the measurement.

A. Supine in low-Fowler's position B. Side-lying with the right side of the chest elevated C. Right lateral in Trendelenburg position D. Prone with pillows under the lower extremities

Correct Answer is C

Explanation

a. Supine in low-Fowler's position - This position is not effective for draining the left lower lobe.

b. Side-lying with the right side of the chest elevated - This position would not effectively drain the left lower lobe.

c. Right lateral in Trendelenburg position - This is correct. Placing the client on their right side with the chest lower than the hips (Trendelenburg position) helps gravity assist in draining secretions from the left lower lobe.

d. Prone with pillows under the lower extremities - This position would not be effective for draining the left lower lobe.

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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?

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