Nokea
The immobile client is in a hospital bed at home. Which information should the home health nurse include when teaching family caregivers how to safely move and reposition the client?
- A. Before moving the client, raise the bed to waist level. After completing the move, return the bed to the lowest level.
- B. The pillow should be removed from under the client's head when positioning in a dorsal recumbent position.
- C. Tighten your abdominal muscles and keep your feet together; use a lift sheet and pull the client up in bed.
- D. When the client is lying on the back, rest the client's heels on the bed and keep the feet perpendicular to the legs.
Correct Answer: A
Rationale: A: Raising the bed to waist level and lowering it after reduces injury risk. B: A pillow prevents neck hyperextension. C: A broad stance, not feet together, improves balance. D: Heels should be off the bed to prevent pressure ulcers.
You may also like to solve these questions
Nail and foot care are essential in meeting basic hygiene needs of clients. Important assessments by the nurse in this area include:
- A. all body assessment, including the feet and nails.
- B. the essential lab work of the client.
- C. the nail beds and the tissue surrounding the nails.
- D. foot corns and calluses only.
Correct Answer: C
Rationale: The nail beds and the tissue surrounding the nails should be assessed for abnormal discoloration, lesions, paronychia (infection of tissue surrounding the nail), tissue dryness, breaks in the skin, pressure areas, or other abnormal appearances.
Which of the following NSAIDS is most commonly used for a brief time for acute pain?
- A. Advil
- B. Aleve
- C. Toradol
- D. Bextra
Correct Answer: C
Rationale: Toradol (ketorolac) is frequently used for short-term acute pain management due to its potent analgesic effects, administered IM, IV, or PO.
The client reports pain in the right leg even though it was amputated. Which complementary therapy should the nurse use to control the phantom pain associated with the client's amputation?
- A. A small dose of alprazolam at 8-hour intervals in addition to prescribed oxycodone and acetaminophen q6h pm
- B. A high-fiber diet and 2000 mL fluid intake in 24 hours while taking hydromorphone at 4- to 6-hour intervals pm
- C. Progressive relaxation exercises three times daily in addition to use of a transdermal patch of fentanyl
- D. A local anesthetic as a nerve block in addition to prescribed long-acting oxycodone
Correct Answer: C
Rationale: C: Progressive relaxation is a complementary therapy that aids phantom pain relief with analgesics. A: Alprazolam is conventional, not complementary. B: Diet addresses opioid side effects, not pain. D: Nerve blocks are conventional medical interventions.
The nurse is developing guidelines to assist personnel in meeting the hygiene needs of clients with dementia. Which guidelines are appropriate for the nurse to include? Select all that apply.
- A. To limit the client's ability to physically resist, two staff should quickly bathe the client.
- B. Include music and dim lighting to create a calm environment when giving a bed bath.
- C. Allow clients who are willing and able to participate in some of the hygienic activities.
- D. Assess for and treat the client's pain before initiating hygienic cares with the client.
- E. Wash the client's hair and body separately if either activity causes the client distress.
Correct Answer: B,C,D,E
Rationale: B: Calm environments reduce agitation. C: Participation fosters cooperation. D: Pain management improves compliance. E: Separating tasks minimizes distress. A: Quick bathing increases agitation.
The client with diarrhea has had four bowel movements in the past eight hours, measuring 150 mL, 100 mL, 100 mL and 150 mL. The client is to receive one-to-one replacement with a bolus of IV 0.9% NaCl to be infused over the next two hours. How many mL of 0.9% NaCl will the nurse infuse each hour?
Correct Answer: 250
Rationale: Total loss is 500 mL (150+100+100+150). One-to-one replacement means 500 mL over 2 hours, so 500/ 2 = 250 mL per hour.