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

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

Reposition the client without the use of assistive devices.

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

The correct answer is choice D. Evaluate the client’s ability to help with repositioning.

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","C","D","E","F"]

Explanation

Answer is B, C, D, E, F. These are the findings that suggest possible elder abuse or neglect.

B: Client’s report of lack of food in home. This may indicate neglect by the adult child who is supposed to provide adequate nutrition for the client.
C: Client’s report of lack of access to bank accounts. This may indicate financial abuse by the adult child who is controlling the client’s money without his permission.
D: Client’s avoidance of eye contact. This may indicate emotional abuse by the adult child who is intimidating or threatening the client.
E: Client’s report of weight loss. This may indicate neglect by the adult child who is not meeting the client’s basic needs or physical abuse by the adult child who is causing bodily harm to the client.
F: Numerous bruises in various stages of healing. This may indicate physical abuse by the adult child who is hitting or injuring the client.

A: ECG results. This is not a finding that suggests elder abuse or neglect. It is a diagnostic test that measures the electrical activity of the heart and can help detect cardiac problems. It does not provide information about the client’s social or emotional well-being.

Normal ranges for vital signs:.

Temperature: 36.1°C to 37.2°C (97°F to 99°F).
Heart rate: 60 to 100 beats per minute.
Blood pressure: less than 120/80 mm Hg.
Respiratory rate: 12 to 20 breaths per minute.
SpO2: 95% to 100% on room air. Table for BMI categories:

BMI	Weight Status
Below 18.5	Underweight
18.5 to 24.9	Normal
25.0 to 29.9	Overweight
30.0 and above	Obese

The client’s BMI is 18.3, which indicates he is underweight and may be malnourished or have a medical condition that causes weight loss.

A. Measure the arm circumference above the insertion site daily. B. Administer sedation C. Schedule an MRI post procedure to verify placement D. Use gauze to secure an arm board to the involved extremity

Correct Answer is A

Explanation

Choice A reason:

Measuring the arm circumference above the insertion site daily is appropriate. When planning care for a client scheduled to receive a peripherally inserted central catheter (PICC) in the arm, it is appropriate for the nurse to include measuring the arm circumference above the insertion site daily. This intervention is essential to monitor for any signs of complications, such as edema or swelling, which could indicate thrombosis or infiltration at the insertion site.

Choice B reason:

Administering sedation Administering sedation is not a routine intervention for a PICC insertion procedure is inappropriate. Sedation might be considered for certain procedures, but it is not typically used for PICC insertions. PICC insertions are generally performed with local anaesthesia at the insertion site.

Choice C reason:

Scheduling an MRI post procedure to verify placement An MRI is not typically used to verify the placement of a PICC. The placement of a PICC is usually confirmed using X-ray or other imaging methods that can visualize the catheter's location within the central veins. Post-procedure verification of PICC placement is essential to ensure proper positioning and to prevent complications.

Choice D reason:

Using gauze to secure an arm board to the involved extremity Using gauze to secure an arm board to the involved extremity is not a common practice for securing a PICC. After a PICC insertion, a securement device specifically designed for PICCs is typically used to secure the catheter in place and prevent movement.

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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 ["B","C","D","E","F"]

Explanation

A nurse is planning care for a client who is scheduled to receive a peripherally inserted central catheter in the arm. Which of the following interventions is appropriate for the nurse to include in the plan of care?

Correct Answer is A

Explanation

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