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

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.

Evaluate the client’s ability to help with repositioning.

Answer and Explanation

The Correct Answer is D

This is because the nurse should assess the client’s level of mobility, strength, and coordination before repositioning them to prevent injury and promote comfort. The nurse should also use appropriate assistive devices, such as a drawsheet, a trapeze bar, or a mechanical lift, to facilitate safe repositioning and reduce the risk of skin breakdown and pressure ulcers.

Choice A is wrong because raising the side rails on both sides of the client’s bed during repositioning can increase the risk of falls and entrapment.

The nurse should only raise the side rail on the opposite side of the bed from where they are working and lower it when they are done.

Choice B is wrong because repositioning the client without assistive devices can cause strain and injury to both the nurse and the client.

The nurse should use assistive devices that are appropriate for the client’s condition and weight.

Choice C is wrong because discussing the client’s preferences for determining a repositioning schedule is not a priority action when preparing to reposition a client who had a stroke.

The nurse should follow the facility’s protocol for repositioning frequency, which is usually every 2 hours, and adjust it according to the client’s needs and comfort.

The nurse should also involve the client in the care plan and respect their preferences whenever possible.

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Correct Answer is B

Explanation

The correct answer is choice b. Using an electronic messaging system to remind clients when to take medications.

Choice A rationale:

Educating clients about contraindications to specific immunizations is an example of primary prevention, which aims to prevent disease before it occurs.

Choice B rationale:

Using an electronic messaging system to remind clients when to take medications is an example of tertiary prevention. It helps manage an existing condition (HIV) by ensuring adherence to treatment, thereby preventing complications and improving quality of life.

Choice C rationale:

Providing clients with information about the benefits of exercise is generally considered primary prevention, as it aims to promote overall health and prevent disease.

Choice D rationale:

Helping clients understand health screenings covered by their insurance plans is an example of secondary prevention, which focuses on early detection and treatment of disease.

A. Preeclampsia. B. Seizures. C. Preterm pre-labor rupture of membranes (PROM). D. Placenta previa. E. Sepsis. F. Disseminated intravascular coagulation.

Correct Answer is ["C","E"]

Explanation

Preterm pre-labor rupture of membranes (PROM) is the spontaneous rupture of the amniotic sac before the onset of labor in a pregnancy less than 37 weeks gestation. It can lead to

infection, cord prolapse, placental abruption, and preterm delivery. The client has risk factors for PROM such as a history of preterm birth and a current infection indicated by fever.

Sepsis is a life-threatening condition that occurs when the body’s response to an infection causes damage to its own tissues and organs. The client has signs of sepsis such as fever, tachycardia, and possible organ dysfunction. The client may have a urinary tract infection, a common cause of sepsis in pregnancy, or an intrauterine infection due to PROM or other factors.

Preeclampsia is not a likely complication for this client because she does not have high blood pressure or proteinuria, which are the defining features of preeclampsia. Seizures are not a likely complication for this client because she does not have epilepsy or eclampsia, which are the leading causes of seizures in pregnancy. Placenta previa is not a likely complication for this client because she does not have painless vaginal bleeding, which is the hallmark symptom of placenta previa.

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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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Naxlex Comprehensive Predictor Exams

A newly licensed nurse working at an HIV clinic is reviewing the responsibilities of her position at the clinic. Which of the following tasks should the nurse identify as tertiary prevention?

Correct Answer is B

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Correct Answer is ["C","E"]

Explanation

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