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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Correct Answer is C

Explanation

Rationale:

A. "I will obtain the client's weight every other day.": Clients receiving TPN require daily weight monitoring to evaluate fluid balance and nutritional effectiveness. Monitoring every other day may delay detection of complications such as fluid overload or inadequate nutrition.

B. "I will monitor the client's blood glucose level every 8 hours.": Blood glucose levels should typically be monitored every 4 to 6 hours, especially during initiation or rate adjustments of TPN. Longer intervals may miss signs of hyperglycemia, a common complication of TPN.

C. "I will hang a new bag of TPN and IV tubing every 24 hours.": Changing the TPN solution and tubing every 24 hours is standard protocol to prevent catheter-related bloodstream infections. TPN solutions are high in glucose, which can promote microbial growth if not properly managed.

D. "I will increase the rate of the TPN infusion to ensure the correct amount is given.”: The TPN infusion rate must never be adjusted without a provider’s order. Altering the rate can lead to serious complications such as hyperglycemia, electrolyte imbalance, or fluid overload.

A. Protamine B. Naloxone C. Hydralazine D. Diphenhydramine

Correct Answer is D

Explanation

Rationale:

A. Protamine: Protamine is used to reverse the effects of heparin, particularly in cases of heparin overdose or to stop excessive bleeding. It does not treat allergic reactions like urticaria.

B. Naloxone: Naloxone is an opioid antagonist used to reverse opioid-induced respiratory depression or overdose. It has no effect on histamine-mediated symptoms such as urticaria.

C. Hydralazine: Hydralazine is an antihypertensive medication that lowers blood pressure by relaxing arterial smooth muscle. It is not appropriate for managing allergic skin reactions.

D. Diphenhydramine: Diphenhydramine is an antihistamine that blocks histamine receptors, making it effective for treating allergic reactions such as urticaria (hives). It reduces itching, swelling, and redness caused by histamine release.

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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?

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