a nurse is caring for a client who is immobile which of the following interventions is appropriate to prevent contractures
Logo

Nursing Elites

ATI LPN

ATI PN Comprehensive Predictor 2020

1. A client who is immobile needs interventions to prevent contractures. Which of the following interventions is appropriate?

Correct answer: C

Rationale: Applying an orthotic to the client's foot is the appropriate intervention to prevent contractures in an immobile client. An orthotic helps maintain proper alignment and prevents the development of contractures by keeping the foot in the correct position. Choices A, B, and D are incorrect because a trochanter wedge, towel roll under the neck, and pillow under the knees are not specific interventions for preventing contractures in an immobile client.

2. When collecting data from a client with posttraumatic stress disorder (PTSD), which of the following manifestations should the nurse expect?

Correct answer: B

Rationale: The correct manifestation to expect when collecting data from a client with PTSD is hypervigilance. Hypervigilance refers to increased alertness, which is a common symptom of PTSD. This heightened state of awareness is characterized by an exaggerated startle response, being easily startled, and constantly scanning the environment for potential threats. Amnesia (choice A) is not typically a primary manifestation of PTSD; it is more commonly associated with dissociative disorders. Hallucinations (choice C) involve perceiving things that are not present and are not typically a hallmark symptom of PTSD. Severe agitation (choice D) may occur in individuals with PTSD, but hypervigilance is a more specific and common manifestation associated with this disorder.

3. A nurse is planning to irrigate and dress a clean, granulating wound for a client. Which of the following actions should the nurse take?

Correct answer: A

Rationale: The correct answer is to irrigate the wound with normal saline. Normal saline is the preferred solution for wound irrigation as it is isotonic and gentle, promoting healing in granulating wounds. Choice B, applying a wet-to-dry gauze dressing, is not appropriate for clean, granulating wounds as it can cause trauma to the wound bed upon removal. Choice C, using a cotton ball to cleanse the wound, is not ideal as cotton fibers can adhere to the wound and cause contamination. Choice D, administering an analgesic after the dressing change, is important for pain management but is not directly related to irrigating and dressing the wound.

4. What is the proper technique for obtaining a blood specimen from a central venous line?

Correct answer: A

Rationale: The correct technique for obtaining a blood specimen from a central venous line is to use sterile gloves and discard the first 10 mL of blood. This practice helps ensure that the blood sample collected is not contaminated. Choice B is incorrect because flushing the line with heparin before drawing the specimen can contaminate the sample. Choice C is incorrect as administering heparin before drawing the specimen can affect the accuracy of the blood sample. Choice D is incorrect as using non-sterile gloves increases the risk of contamination, which is not recommended when obtaining a blood specimen from a central venous line.

5. A healthcare professional is planning care for a client who has a prescription for mechanical restraints. Which of the following interventions should the healthcare professional include in the plan?

Correct answer: B

Rationale: When a client has a prescription for mechanical restraints, it is essential to provide continuous monitoring for their safety and to observe any behavioral changes. Having a staff member stay with the client continuously allows for immediate intervention if needed. Documenting the client's status every 60 minutes (Choice A) may not provide real-time monitoring, which is crucial in this situation. While measuring vital signs every 4 hours (Choice C) is important, continuous observation takes precedence in this scenario. Obtaining a prescription for the restraints every 8 hours (Choice D) is not a necessary intervention once the initial prescription is in place.

Similar Questions

What is the most important action when providing wound care to a client with a pressure ulcer?
How should a healthcare professional assess a patient with chest pain?
A nurse is reviewing the plan of care for a client who is at risk for developing pressure ulcers. Which of the following interventions should the nurse include?
What is the priority for a client with dehydration?
What is the role of a nurse in managing a patient with acute kidney injury (AKI)?

Access More Features

ATI LPN Basic
$69.99/ 30 days

  • 5,000 Questions with answers
  • All ATI courses Coverage
  • 30 days access

ATI LPN Premium
$149.99/ 90 days

  • 5,000 Questions with answers
  • All ATI courses Coverage
  • 30 days access

Other Courses