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 ["A","C","D"]

Explanation

Rationale:

A. "You should eat foods high in protein." Protein is essential for tissue repair and healing, especially after pancreatitis. A diet rich in protein supports recovery and helps maintain muscle mass and immune function.

B. “Limit alcohol intake to no more than one drink per day." Alcohol is a major risk factor for pancreatitis; complete abstinence is necessary to prevent recurrence. Advising to limit intake rather than abstain may lead to misunderstanding and increased risk.

C. "Notify your provider if you experience vomiting or diarrhea." Vomiting and diarrhea may indicate complications such as worsening pancreatitis, infection, or intolerance to diet changes. Early reporting can prevent severe dehydration and further complications.

D. "You should eat foods that are low in fat." Low-fat foods reduce pancreatic stimulation, which is crucial in managing pancreatitis. Consuming high-fat foods can exacerbate symptoms and prolong inflammation.

E. “You can drink beverages that contain caffeine." Caffeine can irritate the gastrointestinal tract and may worsen symptoms in pancreatitis. One should limit or avoid caffeine during recovery.

A. Insert an indwelling urinary catheter. B. Administer packed RBCs. C. Obtain a specimen for ABG analysis. D. Place a large-bore IV catheter in an upper extremity.

Correct Answer is D

Explanation

Rationale:

A. Insert an indwelling urinary catheter: While important for monitoring urine output and renal perfusion, catheter insertion is not the immediate priority in a trauma situation. It should be done after vascular access is secured and life-threatening conditions are addressed.

B. Administer packed RBCs: Blood transfusion is critical for managing hemorrhagic shock, but it cannot be initiated until a large-bore IV is placed. Vascular access is necessary before any fluid or blood product administration.

C. Obtain a specimen for ABG analysis: ABGs provide valuable data on oxygenation and acid-base balance but are diagnostic rather than life-sustaining. This step is less urgent than establishing IV access for fluid resuscitation or transfusion.

D. Place a large-bore IV catheter in an upper extremity: In trauma care, rapid IV access is the top priority to allow fluid and blood product resuscitation. A large-bore catheter ensures high-volume administration, which is essential in potential hemorrhagic shock.

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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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