An older adult client in a long-term care facility had a stroke 4 weeks ago and has been unable to move independently since that time. The nurse caring for her should observe for which of the following findings that indicates a complication of immobility?

Stiffness in the lower extremities

A reddened area over the sacrum

Difficulty hearing some types of sounds

Difficulty moving the upper extremities

Answer and Explanation

The Correct Answer is B

A.   Stiffness in the lower extremities can occur due to lack of movement and muscle disuse. Prolonged immobility leads to muscle atrophy and contractures, causing stiffness and reduced range of motion. This is a common complication seen in clients who are bedridden or have limited mobility.
B.   A reddened area over the sacrum indicates a potential pressure injury or pressure ulcer. Immobility increases the risk of pressure ulcers due to prolonged pressure on bony prominences, such as the sacrum. Regular repositioning and pressure relief strategies are essential to prevent skin breakdown in immobile clients.
C.   Difficulty hearing certain types of sounds is not typically associated with immobility. It may be related to age-related changes in hearing or other auditory issues but is not a direct complication of immobility.
D.   Difficulty moving the upper extremities can occur due to muscle weakness or disuse atrophy, which can result from immobility. However, it is less common compared to stiffness and difficulty in the lower extremities because upper extremities are often more frequently moved or exercised even in bedridden clients.

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Correct Answer is B

Explanation

A. Expulsion of water does not address the underlying issue.
B. Lowering the height of the solution container can help reduce the force of the fluid entering the colon, which may lessen cramping. This method slows the flow rate of the solution, allowing the client's body to adjust without stopping the procedure entirely.
C. Bearing down (straining) may increase the discomfort and is not recommended during the administration of an enema. It could potentially lead to rectal trauma or increase intrarectal pressure, which is not beneficial during the procedure.

D. While stopping the procedure is an option if the client is unable to tolerate it due to severe discomfort or distress, in this scenario where cramping is the main issue, allowing the client to expel some fluid is more appropriate before deciding to stop the procedure.

A. The nurse allows the client to rest in a supine position during feeding. B. The nurse irrigates the NG tube with tap water after feeding. C. The nurse administers the feeding through a syringe barrel by gravity. D. The nurse initiates the feeding after aspirating 50 mL of gastric residual.

Correct Answer is A

Explanation

A. Administering tube feedings while the client is in a supine (flat on their back) position can increase the risk of aspiration. Ideally, clients should be positioned upright or at a 30-45 degree angle during and after tube feedings to reduce the risk of reflux and aspiration.
B. Flushing the NG tube with tap water after feeding is just a standard practice to prevent clogging and maintain tube patency.

C. Administering tube feedings by gravity using a syringe barrel is an appropriate method. This allows for controlled and slow administration of the feeding solution, minimizing the risk of overfeeding or complications.
D. Aspirating gastric residual before initiating tube feedings is a standard practice to assess the amount of residual contents in the stomach. However, the amount of residual aspirate that warrants intervention can vary based on institutional policies and the client's condition.

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An older adult client in a long-term care facility had a stroke 4 weeks ago and has been unable to move independently since that time. The nurse caring for her should observe for which of the following findings that indicates a complication of immobility?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is administering a tap-water enema to a client. The client reports cramping as the nurse instills the irrigating solution. Which of the following actions should the nurse take to relieve the client's discomfort?

Correct Answer is B

Explanation

A charge nurse observes a nurse administer intermittent tube feedings via an NG tube to a client. Which of the following actions should prompt the charge nurse to intervene?

Correct Answer is A

Explanation

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A nurse is collecting data from a client. Which of the following findings should the nurse report to the charge nurse as an indicator of dehydration?

While admitting a client for a cardiac catheterization, the nurse asks the client about allergies. Which of the following client food allergies should the nurse report to the provider prior to the procedure?

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