The nurse is repositioning a patient who has a spinal injury and notes reddened areas on the heels of both feet. The nurse should place the patient in which of the following positions?

Lateral heels offloaded with pillows

Supine heels offloaded with pillows

Fowler's heels offloaded with pillows

Prone ankles offloaded with pillows.

Answer and Explanation

The Correct Answer is A

A. Lateral heels offloaded with pillows: Positioning the patient laterally with heels offloaded helps reduce pressure on the heels and prevent pressure sores.

B. Supine heels offloaded with pillows: Although offloading the heels is important, the supine position may still exert pressure on the heels and does not provide as effective offloading as the lateral position.

C. Fowler's heels offloaded with pillows: Fowler’s position may still place some pressure on the heels, even with pillows for offloading.

D. Prone ankles offloaded with pillows: The prone position is generally not recommended for patients with spinal injuries, and it does not effectively address heel pressure.

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Correct Answer is ["B","D"]

Explanation

A. Clean skin using a side to side motion. The skin should be cleaned in a circular motion from the center outward to reduce the risk of infection.

B. Keep skin pinched while injecting medication. Pinching the skin helps create a small "pocket" for the injection, making it easier to administer the medication subcutaneously.

C. Apply firm pressure to the injection site. Applying firm pressure is not recommended immediately after the injection as it can cause discomfort and does not affect absorption. Gentle pressure is usually recommended.

D. Insert the needle at a 45 or 90-degree angle. For subcutaneous injections, a 45-degree angle is often recommended for thinner individuals, while a 90-degree angle is appropriate for those with more tissue.

A. Small muscle twitching. B. An increase in temperature. C. Difficult to arouse. D. An increase in pulse rate.

Correct Answer is C

Explanation

A. Small muscle twitching. Small muscle twitching is more common during REM sleep, not Stage IV NREM sleep.

B. An increase in temperature. Stage IV NREM sleep is associated with stable body temperature rather than an increase.

C. Difficult to arouse. Stage IV NREM sleep is known as deep sleep, and individuals are indeed difficult to arouse during this stage.

D. An increase in pulse rate. Stage IV NREM sleep typically features a stable or decreased pulse rate, not an increase.

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The nurse is repositioning a patient who has a spinal injury and notes reddened areas on the heels of both feet. The nurse should place the patient in which of the following positions?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is ["B","D"]

Explanation

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Correct Answer is C

Explanation

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