A nurse provides a back massage as palliative care to an unconscious client who is grimacing and restless. Which of the following indicates a therapeutic response? (Select all that apply.)

The client draws his legs up into a fetal position.

The facial muscles relax.

The respiratory rate increases.

The shoulders droop.

The pulse is within the expected range

Answer and Explanation

Correct Answer : B,D,E

A.   Drawing legs up into a fetal position may indicate discomfort or agitation.
B.   Facial muscle relaxation is indicative of a therapeutic response to the massage.
C.   An increased respiratory rate may suggest distress or discomfort.
D.   Drooping shoulders suggest relaxation and a positive response to the massage.
E.   Maintaining an expected pulse rate indicates that the massage is not causing undue stress or discomfort.

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Correct Answer is A

Explanation

A. Lactated Ringer’s is the preferred fluid for fluid resuscitation in the first 24 hours after a burn injury as it helps replace lost fluids and electrolytes.
B. Dextrose 5% in water is not the primary fluid for burn resuscitation.
C. 0.9% sodium chloride may be used, but Lactated Ringer’s is often preferred.
D. Dextrose 5% in 0.9% sodium chloride is not the primary fluid for burn resuscitation.

A. Instruct the client to stay in the bathtub no longer than 20 min. B. Fill the bathtub with water at 48 C (118.4° F). C. Use bath oil in the client’s bathtub D. Provide the client with non-slip bath strips in the bathtub.

Correct Answer is D

Explanation

A. The duration of time in the bathtub should be based on the client's tolerance but should not exceed 20 minutes.
B. Water temperature should be warm but not excessively hot to avoid burns or discomfort.
C. Bath oils can make the bathtub slippery and increase the risk of falls. They should be avoided.
D. Providing non-slip bath strips enhances safety and helps prevent the client from slipping in the bathtub.

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A nurse provides a back massage as palliative care to an unconscious client who is grimacing and restless. Which of the following indicates a therapeutic response? (Select all that apply.)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is monitoring the fluid replacement of a client who has sustained burns. Which of the following fluids should the nurse use in the first 24 hr following a client’s burn injury?

Correct Answer is A

Explanation

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Correct Answer is D

Explanation

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A nurse provides a back massage as palliative care to an unconscious client who is grimacing and restless. Which of the following indicates a therapeutic response? (Select all that apply.)

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