A nurse is teaching about safe positioning with the caregiver of a client who has right-sided hemiplegia following a stroke. Which of the following statements by the caregiver indicates an understanding of the teaching?
"I will ensure their neck is flexed backwards when they're lying on their stomach."
"I will support their feet with a rolled pillow when they are lying on their back."
"I will rest their heels on the mattress when they are sitting up in bed."
"I will use a thick pillow under their head to support the neck."
The Correct Answer is B
B. Supporting the feet with a rolled pillow helps prevent foot drop (a common issue in hemiplegia). It maintains the ankle in a neutral position, preventing contractures.
A. When lying on the stomach (prone position), the neck should be neutral (neither flexed nor extended). Flexing the neck backward can strain the cervical spine and compromise airway alignment.
C. For a client with right-sided hemiplegia, the affected leg (right leg) should be supported to prevent foot drop.
D. A thick pillow under the head can cause neck hyperextension.
The head should be supported with a small, firm pillow to maintain a neutral neck position.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. This position may help alleviate dyspnea by promoting better lung expansion. However, it does not address the underlying issue of fluid overload or the need for urgent action. While helpful for comfort, this action alone is insufficient.
B. Switching the IV fluid to lactated Ringer's solution does not address the issue of fluid overload and is likely to worsen the situation.
C. Slowing the infusion can help mitigate further fluid overload, and contacting the provider is crucial for further evaluation and intervention. This option prioritizes the client’s safety and addresses the symptoms being experienced.
D. Corticosteroids are not typically used to address dyspnea and hypertension associated with IV fluid administration.
Correct Answer is C
Explanation
C. Metabolic alkalosis is characterized by an increase in serum bicarbonate levels, resulting in an imbalance in the body's acid-base equilibrium towards alkalinity. Excessive ingestion of antacids, particularly those containing bicarbonate or calcium carbonate, can lead to an excessive accumulation of bicarbonate ions in the body, causing metabolic alkalosis.
A. Excessive ingestion of antacids would not typically cause metabolic acidosis because antacids containing bicarbonate or calcium carbonate actually increase bicarbonate levels, leading to alkalosis rather than acidosis.
B. Respiratory alkalosis occurs due to hyperventilation, leading to a decrease in carbon dioxide levels and subsequent alkalosis. Excessive ingestion of antacids is not typically associated with respiratory alkalosis.
D. Respiratory acidosis occurs due to hypoventilation, leading to an increase in carbon dioxide levels and subsequent acidosis. Excessive ingestion of antacids is not typically associated with respiratory acidosis.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.