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NurseDive Free Nursing Practice Question
A nurse is teaching about safe positioning with the caregiver of a client who has right-sided hemiplegia following a stroke. Which of the following statements by the caregiver indicates an understanding of the teaching?
A. "I will ensure their neck is flexed backwards when they're lying on their stomach."
When lying on the stomach (prone position), the neck should be neutral (neither flexed nor extended). Flexing the neck backward can strain the cervical spine and compromise airway alignment.
B. "I will support their feet with a rolled pillow when they are lying on their back."
Supporting the feet with a rolled pillow helps prevent foot drop (a common issue in hemiplegia). It maintains the ankle in a neutral position, preventing contractures.
C. "I will rest their heels on the mattress when they are sitting up in bed."
For a client with right-sided hemiplegia, the affected leg (right leg) should be supported to prevent foot drop.
D. "I will use a thick pillow under their head to support the neck."
A thick pillow under the head can cause neck hyperextension.The head should be supported with a small, firm pillow to maintain a neutral neck position.
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Full Explanation
B. Supporting the feet with a rolled pillow helps prevent foot drop (a common issue in hemiplegia). It maintains the ankle in a neutral position, preventing contractures.
A. When lying on the stomach (prone position), the neck should be neutral (neither flexed nor extended). Flexing the neck backward can strain the cervical spine and compromise airway alignment.
C. For a client with right-sided hemiplegia, the affected leg (right leg) should be supported to prevent foot drop.
D. A thick pillow under the head can cause neck hyperextension.
The head should be supported with a small, firm pillow to maintain a neutral neck position.
Similar Questions
A nurse is planning care for a client who has bacterial meningitis. Which of the following interventions should the nurse implement?
A. Ensure the client's bed is positioned to greater than 45°.
The head of the bed should be elevated to 30 degrees to reduce intracranial pressure.
B. Initiate airborne precautions.
Bacterial meningitis is transmitted through hematogenous route and airborne precautions are not always necessary.
C. Ensure lights are dimmed in the client's room.
Clients with meningitis may be sensitive to light, dimming the lights should be implemented to increase comfort by reducing stimuli.
D. Encourage frequent ambulation.
Encourage frequent ambulation is not appropriate for bacterial
Full Explanation
A. The head of the bed should be elevated to 30 degrees to reduce intracranial pressure.
B. Bacterial meningitis is transmitted through hematogenous route and airborne precautions are not always necessary.
C. Clients with meningitis may be sensitive to light, dimming the lights should be implemented to increase comfort by reducing stimuli.
D. Encourage frequent ambulation is not appropriate for bacterial
A nurse is assessing a client who is taking telmisartan. The nurse should identify that which of the following findings indicates that the medication has been effective?
A. Respiratory rate of 16/min
B. Decrease in blood pressure
Telmisartan is an angiotensin II receptor blocker (ARB) used to treat hypertension by lowering blood pressure. Therefore, a decrease in blood pressure would suggest that the medication is working as intended. Telmisartan has no effect on respiratory rate, urine output or blood glucose.
C. Increase in urinary output
D. Blood glucose of 110 mg/dL
Full Explanation
Telmisartan is an angiotensin II receptor blocker (ARB) used to treat hypertension by lowering blood pressure. Therefore, a decrease in blood pressure would suggest that the medication is working as intended.
Telmisartan has no effect on respiratory rate, urine output or blood glucose.
A nurse is caring for a client who is receiving mechanical ventilation when the low-pressure alarm sounds on the ventilator. Which of the following actions should the nurse take?
A. Suction the client's airway.
Suctioning the client's airway is not the appropriate action in response to a low-pressure alarm on the ventilator.
B. Empty water from the client's ventilator tubing.
Emptying water from the client's ventilator tubing could be a valid action to take if there is excess condensation or water buildup in the ventilator tubing causing the low-pressure alarm. However, it's not the first action to consider, as other causes should be ruled out first.
C. Increase the client's ventilator flow rate.
Increasing the ventilator flow rate may help maintain adequate pressure in the ventilator circuit and address the low-pressure alarm if the cause is related to insufficient airflow. However, adjusting the flow rate should be done cautiously and based on the client's respiratory status and ventilator settings.
D. Evaluate the client for a cuff leak.
Evaluate the client for a cuff leak is the most appropriate action in response to a low-pressure alarm on the ventilator. A cuff leak can cause a drop in ventilator pressure, triggering the alarm. Assessing the client's cuff for leaks and addressing any identified issues can help resolve the alarm and ensure adequate ventilation.
Full Explanation
D. Evaluate the client for a cuff leak is the most appropriate action in response to a low-pressure alarm on the ventilator. A cuff leak can cause a drop in ventilator pressure, triggering the alarm. Assessing the client's cuff for leaks and addressing any identified issues can help resolve the alarm and ensure adequate ventilation.
A. Suctioning the client's airway is not the appropriate action in response to a low-pressure alarm on the ventilator.
B. Emptying water from the client's ventilator tubing could be a valid action to take if there is excess condensation or water buildup in the ventilator tubing causing the low-pressure alarm. However, it's not the first action to consider, as other causes should be ruled out first.
C. Increasing the ventilator flow rate may help maintain adequate pressure in the ventilator circuit and address the low-pressure alarm if the cause is related to insufficient airflow. However, adjusting the flow rate should be done cautiously and based on the client's respiratory status and ventilator settings.