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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Rationale:
A. Weigh the client before and after the procedure: Weighing the client helps to assess the volume of fluid removed and its immediate impact on the client’s body weight. This also assists in evaluating the effectiveness of the procedure and monitoring for fluid imbalances or complications.
B. Administer a low-volume hypertonic enema the night before the procedure: Enemas are not indicated for paracentesis, which involves the peritoneal cavity, not the bowel. Preparing the bowel is not necessary for this procedure and does not influence its safety or effectiveness.
C. Place the client in a side-lying position for the procedure: Paracentesis is typically performed with the client in a semi- to high-Fowler’s position. This position causes ascitic fluid to collect in the lower abdomen, making it more accessible and reducing the risk of organ puncture.
D. Ensure the client has a full bladder just prior to the procedure: The bladder should be emptied before paracentesis to reduce the risk of accidental puncture. A full bladder increases the chance of bladder injury during the needle insertion into the peritoneal cavity.
Correct Answer is B
Explanation
Rationale:
A. Limit your fluid intake to 500 milliliters per day: Restricting fluids to this extent can lead to dehydration and concentrated urine, which may irritate the bladder and worsen incontinence symptoms. Maintaining adequate hydration is essential during bladder retraining.
B. Plan to urinate every 3 hours while you are awake: Scheduled voiding every 2 to 3 hours helps train the bladder to hold urine for longer intervals and reduces urgency episodes. This is a core component of effective bladder retraining for urge incontinence.
C. Decrease your intake of cranberry juice: Cranberry juice may help prevent urinary tract infections, though its benefit in incontinence management is limited. There is no need to avoid it unless advised for another reason, as it is not a known bladder irritant.
D. Take your diuretic medication with your evening meal: Taking diuretics late in the day increases nighttime urine production, leading to nocturia and disturbed sleep. Diuretics should be taken in the morning to align with daytime urinary patterns and reduce bladder strain at night.
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