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How would the nurse position the client with burns of the head, neck, chest, right arm and hand to prevent contractures?

Laterally on the left side with a pillow under the head and the right arm and hand hyperextended

Supine with a pillow under the head, and elevate the right hand and arm on a pillow

Semi-Fowler's position without a pillow under the head, and the right arm and hand elevated on a pillow

Prone without a pillow, and with the right arm and hand flexed in a position of comfort and elevated on a pillow

Answer and Explanation

The Correct Answer is C

A. Laterally on the left side

Lateral positioning may not fully prevent contractures.

B. Supine with a pillow under the head

A pillow under the head can cause neck contractures.

C. Semi-Fowler’s without a pillow, right arm & hand elevated

Prevents contractures and promotes drainage of edema.

D. Prone without a pillow

Prone position increases discomfort and risk of respiratory complications.

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Correct Answer is ["A","C","D"]

Explanation

A. Administer each unit of blood over 3–4 hours

Older clients with CHF cannot tolerate rapid fluid shifts. Blood should be administered slowly (over 3–4 hours per unit) to prevent fluid overload.

B. Anticipate an order for acetaminophen

Acetaminophen is not routinely given before blood transfusions unless the client has a history of febrile reactions.

C. Anticipate an order for furosemide administration

Loop diuretics like furosemide may be ordered between units to prevent fluid overload in CHF patients.

D. Assess for signs and symptoms of fluid overload

CHF patients are at high risk for fluid overload, leading to dyspnea, crackles, and increased BP.

E. Anticipate administration of fresh frozen plasma (FFP) for the next transfusion

FFP is given for coagulation disorders, not for treating anemia in a GI bleed.

A. sudden onset of chest pain and copious sputum B. foul smelling concentrated urine C. oozing blood from iv sites & previous venipuncture sites D. reddened, inflamed central line catheter site

Correct Answer is C

Explanation

A. Sudden onset of chest pain and copious sputum

These are more consistent with pulmonary edema or a respiratory infection, not DIC.

B. Foul-smelling concentrated urine

This is suggestive of a urinary tract infection (UTI) or dehydration but is not a hallmark sign of DIC.

C. Oozing blood from IV sites & previous venipuncture sites

DIC is a disorder of excessive clotting and subsequent bleeding. Uncontrolled bleeding from IV sites, surgical wounds, or mucous membranes is a classic sign.

D. Reddened, inflamed central line catheter site

While redness around a catheter site may indicate infection, it is not a defining feature of DIC.

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How would the nurse position the client with burns of the head, neck, chest, right arm and hand to prevent contractures?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is caring for an 82-year-old client with a history of coronary artery disease. ML. and CHF. The client is to receive 2 units of packed red blood cells for acute blood loss from a Grbleed. What would be the nursing priorities for blood administration of this client? (Select All that Apply)

Correct Answer is ["A","C","D"]

Explanation

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Correct Answer is C

Explanation

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