Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
A nurse is planning care for a client who is immobile. Which of the following actions should the nurse include in the plan of care?
A. Use trochanter rolls beside the client's legs.
Use trochanter rolls beside the client's legs:Trochanter rolls are positioning devices placed alongside the thighs to prevent external rotation of the hips when a client is lying supine. This helps maintain proper alignment and prevents hip contractures, especially in clients who are immobile.
B. Logroll the client every 4 hr.
Logroll the client every 4 hr:Logrolling is a technique used to turn a client with spinal precautions, such as after spinal surgery or injury. It involves turning the entire body as a unit to avoid twisting the spine. However, in a general plan of care for an immobile client, logrolling every 4 hours may not be necessary unless there are specific medical indications.
C. Place the client's arms at their side when turning them.
Place the client's arms at their side when turning them:Placing the client's arms at their side may not be the most optimal positioning during turns, as it can contribute to joint contractures. The nurse should consider positioning the arms in a manner that maintains joint flexibility and prevents contractures.
D. Cross the client's ankles when lying supine.
Cross the client's ankles when lying supine:Crossing the client's ankles when lying supine is not a recommended practice. It can lead to pressure on the lateral aspect of the knees and ankles, potentially causing discomfort and impairing circulation. It is important to maintain proper alignment and support for the client's lower extremities.
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Full Explanation
A. Use trochanter rolls beside the client's legs:
Trochanter rolls are positioning devices placed alongside the thighs to prevent external rotation of the hips when a client is lying supine. This helps maintain proper alignment and prevents hip contractures, especially in clients who are immobile.
B. Logroll the client every 4 hr:
Logrolling is a technique used to turn a client with spinal precautions, such as after spinal surgery or injury. It involves turning the entire body as a unit to avoid twisting the spine. However, in a general plan of care for an immobile client, logrolling every 4 hours may not be necessary unless there are specific medical indications.
C. Place the client's arms at their side when turning them:
Placing the client's arms at their side may not be the most optimal positioning during turns, as it can contribute to joint contractures. The nurse should consider positioning the arms in a manner that maintains joint flexibility and prevents contractures.
D. Cross the client's ankles when lying supine:
Crossing the client's ankles when lying supine is not a recommended practice. It can lead to pressure on the lateral aspect of the knees and ankles, potentially causing discomfort and impairing circulation. It is important to maintain proper alignment and support for the client's lower extremities.
Similar Questions
A nurse is caring for a client who reports that she has insomnia. Which of the following interventions is appropriate for the nurse to recommend?
A. Exercise 1 hr before bedtime.
Exercise 1 hr before bedtime:While regular exercise is beneficial for overall health, exercising close to bedtime may actually interfere with sleep. It is better to exercise earlier in the day.
B. Drink a cup of hot cocoa before bedtime.
Drink a cup of hot cocoa before bedtime:While a warm beverage like hot cocoa may be soothing for some individuals, it contains caffeine, which can interfere with sleep. Caffeine consumption, especially close to bedtime, is generally discouraged for those experiencing insomnia.
C. Eat a light carbohydrate snack before bedtime..
Eating a light carbohydrate snack before bedtimecan help promote sleep. Carbohydrates increase the availability of tryptophan, an amino acid that contributes to the production of serotonin (a neurotransmitter associated with relaxation and sleep).However, the snack should be light and not too heavy to avoid discomfort or indigestion during sleep.
D. Take a 30-min nap daily.
Take a 30-min nap daily:Taking a 30-minute nap daily may not be the most effective intervention for insomnia. Napping during the day can interfere with nighttime sleep, especially if it's taken too close to bedtime. Short naps earlier in the day are generally recommended if needed.
Full Explanation
A. Exercise 1 hr before bedtime:
While regular exercise is beneficial for overall health, exercising close to bedtime may actually interfere with sleep. It is better to exercise earlier in the day
B. Drink a cup of hot cocoa before bedtime:
While a warm beverage like hot cocoa may be soothing for some individuals, it contains caffeine, which can interfere with sleep. Caffeine consumption, especially close to bedtime, is generally discouraged for those experiencing insomnia.
C. Eat a light carbohydrate snack before bedtime: can help promote sleep. Carbohydrates increase the availability of tryptophan, an amino acid that contributes to the production of serotonin (a neurotransmitter associated with relaxation and sleep).However, the snack should be light and not too heavy to avoid discomfort or indigestion during sleep
.
D. Take a 30-min nap daily:
Taking a 30-minute nap daily may not be the most effective intervention for insomnia. Napping during the day can interfere with nighttime sleep, especially if it's taken too close to bedtime. Short naps earlier in the day are generally recommended if needed.
A nurse is teaching a group of newly licensed nurses about the Braden scale. Which of the following responses by a newly licensed nurse indicates an understanding of the teaching?
A. "The higher the score, the higher the pressure injury risk."
The Braden Scale measures pressure injury risk, but a higher score indicates a lower risk of developing a pressure injury.
B. The client's age is part of the measurement."
The client’s age is not a direct factor measured by the Braden Scale.
C. "Each element has a range from one to five points."
Each element in the Braden Scale is scored from 1 to 4 points. A score of 1 indicates the highest level of impairment for that element, while a score of 4 indicates the least impairment.
D. "The scale measures six elements."
The Braden Scale evaluates six elements: Sensory perception, Moisture, Activity, Mobility, Nutrition and Friction/shear. These elements are critical for assessing a client’s risk of developing pressure injuries.
Full Explanation
A. "The higher the score, the higher the pressure injury risk.": The Braden Scale measures pressure injury risk, but a higher score indicates a lower risk of developing a pressure injury.
B. "The client's age is part of the measurement.": The client’s age is not a direct factor measured by the Braden Scale.
C. "Each element has a range from one to five points.": Each element in the Braden Scale is scored from 1 to 4 points. A score of 1 indicates the highest level of impairment for that element, while a score of 4 indicates the least impairment.
D. "The scale measures six elements.":
The Braden Scale evaluates six elements: Sensory perception, Moisture, Activity, Mobility, Nutrition and Friction/shear. These elements are critical for assessing a client’s risk of developing pressure injuries.
A nurse is preparing to perform an anthropometric assessment on a client. Which of the following client data should the nurse include?
A. Respiratory rate
Respiratory rate:Respiratory rate is not part of an anthropometric assessment. Anthropometry primarily focuses on physical measurements related to body size, composition, and proportions.
B. Weight
Weight:Anthropometric assessment involves the measurement of various body dimensions, and weight is a changes over time, and contribute to the overall understanding of a client's health and well-being.
C. Current pain level
Current pain level:Pain level is not typically included in an anthropometric assessment. Anthropometry is more concerned with physical measurements and does not directly assess subjective experiences like pain.
D. Level of orientation
Level of orientation: Level of orientation is not a component of an anthropometric assessment. Anthropometry is concerned with objective physical measurements and does not assess cognitive or perceptual factors.
Full Explanation
A. Respiratory rate:
Respiratory rate is not part of an anthropometric assessment. Anthropometry primarily focuses on physical measurements related to body size, composition, and proportions.
B. Weight:
Anthropometric assessment involves the measurement of various body dimensions, and weight is a
changes over time, and contribute to the overall understanding of a client's health and well-being.
C. Current pain level:
Pain level is not typically included in an anthropometric assessment. Anthropometry is more concerned with physical measurements and does not directly assess subjective experiences like pain.
D. Level of orientation:
Level of orientation is not a component of an anthropometric assessment. Anthropometry is concerned with objective physical measurements and does not assess cognitive or perceptual factors.