A nurse is preparing to reposition a client who had a stroke. Which of the following actions should the nurse take?

Evaluate the client's ability to help with repositioning

Reposition the client without the use of assistive devices.

Raise the side rails on both sides of the client's bed during repositioning

Discuss the client's preferences for determining a repositioning schedule

Answer and Explanation

The Correct Answer is A

Rationale:

A. Evaluate the client's ability to help with repositioning: Assessing the client's motor function and ability to assist is essential for planning a safe and effective repositioning strategy. It helps prevent injury to both the client and staff and allows for appropriate use of equipment or assistance.

B. Reposition the client without the use of assistive devices: Clients with impaired mobility due to stroke are at increased risk for injury during movement. Assistive devices should be used as needed to ensure safe and proper repositioning.

C. Raise the side rails on both sides of the client's bed during repositioning: Raising both side rails can create a restraint-like situation and may increase fall risk. Only the side rail on the opposite side of movement should be raised for safety during repositioning.

D. Discuss the client's preferences for determining a repositioning schedule: While involving the client in care decisions is important, repositioning schedules are primarily based on clinical needs (e.g., immobility, pressure ulcer prevention), not solely on preference.

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Free Nursing Study Resources

Correct Answer is {"A":{"answers":"A"},"B":{"answers":"A"},"C":{"answers":"B"},"D":{"answers":"A"}}

Explanation

Rationale:

Insert a nasogastric tube and maintain low intermittent suction: This is anticipated to help decompress the stomach, reduce nausea and vomiting, and prevent aspiration in a client with severe pancreatitis who is vomiting and has abdominal distension.
Administer IV lactated Ringer's: IV fluids are critical for hydration and to correct electrolyte imbalances in acute pancreatitis. Lactated Ringer’s is preferred over normal saline because it better maintains acid-base balance.
Insert an indwelling urinary catheter: This is generally contraindicated unless necessary, as it increases the risk of infection. No information indicates urinary retention or need for strict output monitoring that outweighs infection risks.
Administer IV famotidine: Famotidine reduces gastric acid secretion, which helps protect the gastric mucosa and may be beneficial in preventing stress ulcers in critically ill clients. It is appropriate in this situation.

A. Inject into the vastus lateralis B. Roll the syringe gently to ensure mixture of the insulins C. Draw up regular insulin prior to NPH insulin D. Use a 15 angle for the injection

Correct Answer is C

Explanation

Rationale:

A. Inject into the vastus lateralis: The preferred injection sites for insulin are subcutaneous areas such as the abdomen, upper arms, thighs, or buttocks. The vastus lateralis is used for intramuscular injections, not subcutaneous insulin administration.

B. Roll the syringe gently to ensure mixture of the insulins: Only the NPH (cloudy) insulin should be rolled gently between the hands to mix it evenly before drawing it up. The syringe itself should not be rolled after both insulins are inside, as this may affect accuracy.

C. Draw up regular insulin prior to NPH insulin: When mixing insulins, regular (clear) insulin should be drawn up first to avoid contaminating the vial of regular insulin with the cloudy NPH insulin, which could alter its action and absorption.

D. Use a 15 angle for the injection: Insulin is administered subcutaneously using a 45- to 90-degree angle, depending on the client’s body habitus. A 15-degree angle is too shallow and is used for intradermal injections, not subcutaneous ones.

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A nurse is preparing to reposition a client who had a stroke. Which of the following actions should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is {"A":{"answers":"A"},"B":{"answers":"A"},"C":{"answers":"B"},"D":{"answers":"A"}}

Explanation

A nurse is providing teaching to a client who has a new diagnosis of type 1 diabetes mellitus about administering NPH insulin and regular insulin together in one injection. Which of the following instructions should the nurse include?

Correct Answer is C

Explanation

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