Question

A client has a blood sodium level of 128 mEq/L (136–145 mEq/L). Which finding will the nurse expect for the client?

Answer 1

Correct Answers:

Tachycardia

Rationale :

Tachycardia

⚽ Hyponatremia, defined as a serum sodium level below 136 mEq/L, decreases plasma osmolality and leads to fluid shifts from the extracellular to intracellular space.

⚽ Tachycardia occurs as a compensatory cardiovascular response to maintain adequate tissue perfusion when circulating blood volume is altered.

⚽ Fluid shifts can cause hypovolemia, which stimulates the sympathetic nervous system, increasing heart rate to preserve cardiac output.

⚽ This response is especially prominent in older adults or those with comorbidities affecting cardiovascular function.

⚽ Other signs may include hypotension, dizziness, and decreased urine output, which are all indirect indicators of low sodium levels affecting circulation.

⚽ Rapid identification and monitoring of vital signs in hyponatremic clients is a priority nursing intervention.

⚽ Intervention includes careful correction of sodium levels and monitoring for fluid overload or neurologic changes.

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Answer 2

Correct Answers:

"I will keep one point of support on the ground at all times."

Rationale :

"I will keep one point of support on the ground at all times."

✨ Maintaining one point of support on the ground ensures stability for clients using a cane and reduces the risk of falls.

✨ This practice aligns with the basic principles of assistive device use, which emphasize continuous support during ambulation.

✨ It allows the client to distribute weight safely, keeping balance while moving forward.

✨ The cane should always be positioned on the stronger or unaffected side to provide maximum support.

✨ Keeping one point on the ground prevents sudden loss of support, particularly important for clients with muscle weakness or gait instability.

✨ Continuous contact with the ground enables the client to react quickly to obstacles or uneven surfaces, enhancing safety.

✨ Proper cane use promotes independence and confidence in mobility.

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Answer 3

Correct Answers:

"This device improves circulation to your legs."

Rationale :

"This device improves circulation to your legs."

🖊️ Promotes Venous Return – Sequential compression devices (SCDs) apply intermittent pressure to the legs, helping push venous blood back toward the heart, which prevents blood pooling in the lower extremities.

🖊️ Prevents Deep Vein Thrombosis (DVT) – By improving circulation, SCDs reduce the risk of clot formation in post-surgical clients who are immobile.

🖊️ Reduces Edema – The rhythmic compression helps to decrease lower limb swelling, maintaining optimal tissue perfusion.

🖊️ Non-invasive Intervention – SCDs are a mechanical method to support circulation without the use of medications.

🖊️ Complements Other DVT Measures – Using SCDs along with early ambulation and anticoagulant therapy enhances prevention of post-operative complications.

🖊️ Comfortable and Safe – The device is generally well-tolerated and can be used continuously while the patient is in bed.

🖊️ Patient Education – Teaching emphasizes proper fit and continued use for maximal benefit, ensuring patients understand its purpose and safety.

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Answer 4

Correct Answers:

Risk for pressure injuries to bony prominences.

Rationale :

Risk for pressure injuries to bony prominences.

✨ Prolonged immobility in hospitalized clients reduces blood flow to bony prominences, increasing the risk of pressure injuries.

✨ Pressure, friction, and shear forces exerted on areas such as the sacrum, heels, and elbows can damage underlying skin and tissue, especially over time.

✨ Older adults or clients with nutritional deficits are particularly vulnerable to skin breakdown when immobile.

✨ Maintaining skin integrity through frequent repositioning and use of pressure-relieving devices is essential to prevent ulcers and infections.

✨ Moisture from incontinence or sweating further increases the risk, requiring skin care and barrier protection.

✨ Regular skin assessments should be performed to identify early signs of erythema, edema, or blanching, which are indicators of potential pressure injuries.

✨ Education for the client and caregivers on turning schedules and proper support surfaces can reduce complication risk.

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Answer 5

Correct Answers:

Footboard

Rationale :

Footboard

🧿 A footboard is designed to maintain the feet in a neutral position and prevent the toes from pointing downward, which can lead to plantar flexion contractures.

🧿 Plantar flexion contractures occur when the muscles and tendons of the calf shorten, limiting dorsiflexion of the foot and interfering with mobility.

🧿 Use of a footboard promotes proper alignment of the lower extremities while the client is immobilized in bed.

🧿 It provides a stable surface against which the client can flex the ankles, encouraging range of motion and preventing deformities.

🧿 Regular monitoring and positioning with the footboard reduce the risk of complications such as pressure injuries and joint stiffness associated with prolonged immobility.

🧿 The footboard is particularly effective for clients on prolonged bed rest or those in traction to maintain optimal musculoskeletal function.

🧿 It is an independent nursing intervention that can be implemented without additional orders, ensuring preventive care for immobile clients.

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Answer 6

Correct Answers:

The client's current weight-bearing status

Rationale :

The client's current weight-bearing status

⚽ Determining the client's weight-bearing status is essential to ensure the safety of both the client and nurse during the transfer.

⚽ Weight-bearing restrictions guide the method of transfer, such as full support, partial support, or using assistive devices.

⚽ Incorrect transfer methods for clients with limited weight-bearing can cause falls, fractures, or injury to surgical sites.

⚽ The nurse must verify the client's current functional mobility rather than relying solely on prior transfers or general assumptions.

⚽ Knowledge of weight-bearing capacity allows proper planning for using mechanical lifts, gait belts, or assistance from another staff member.

⚽ Ensuring adherence to weight-bearing instructions supports optimal healing and prevents complications such as stress on healing bones or joints.

⚽ Safe transfer techniques reduce the risk of musculoskeletal injuries for both the client and healthcare provider.

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Answer 7

Correct Answers:

Stasis of secretions and decreased cough response
Constipation
Stasis of blood in the legs

Rationale :

Stasis of secretions and decreased cough response

🧿 Immobility reduces lung expansion, which decreases clearance of respiratory secretions.

🧿 Stasis of secretions increases risk of respiratory infections such as pneumonia.

🧿 Muscle inactivity weakens the diaphragm and accessory muscles, limiting cough effectiveness.

🧿 Bedrest decreases stimulation for deep breathing, compounding secretion accumulation.

🧿 Immobility can lead to hypoventilation, causing retained CO₂ and lower oxygenation.

🧿 Clients may develop atelectasis, which can worsen oxygen exchange.

🧿 Frequent repositioning and pulmonary exercises are key nursing interventions to prevent these complications.

Constipation

🧿 Immobility slows gastrointestinal motility, increasing the risk of constipation.

🧿 Decreased peristalsis from inactivity leads to prolonged stool transit time.

🧿 Bedrest reduces abdominal muscle tone, which is needed for effective defecation.

🧿 Low fluid intake and poor dietary fiber intake during immobility can worsen constipation.

🧿 Constipation increases risk for discomfort, fecal impaction, and hemorrhoids.

🧿 Nursing interventions include ensuring adequate hydration and ambulation if possible.

🧿 Routine monitoring of bowel movements is essential to prevent complications.

Stasis of blood in the legs

🧿 Immobility slows venous return from the lower extremities, creating blood pooling.

🧿 Venous stasis increases the risk for deep vein thrombosis (DVT).

🧿 Inactive muscles do not assist in venous return via the muscle pump mechanism.

🧿 Edema may develop in the lower extremities due to fluid accumulation.

🧿 DVT can lead to life-threatening complications such as pulmonary embolism.

🧿 Nursing interventions include leg exercises, sequential compression devices, and anticoagulant therapy if prescribed.

🧿 Frequent assessment of leg color, temperature, and circumference is essential to detect early complications.

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Answer 8

Correct Answers:

"Contact your healthcare provider if you experience increased pain."

Rationale :

"Contact your healthcare provider if you experience increased pain."

⚽ Postoperative pain can indicate complications such as infection, bleeding, or deep vein thrombosis.

⚽ Early recognition and reporting of increased pain allows timely intervention to prevent worsening conditions.

⚽ Arthroscopic knee surgery is minimally invasive, but increased pain is not typical and warrants evaluation.

⚽ Clients should monitor pain levels at home and communicate changes promptly to the healthcare provider.

⚽ Pain control is essential for proper healing and early mobilization post-surgery.

⚽ Patient education should emphasize symptoms like swelling, redness, warmth, or decreased range of motion along with pain.

⚽ Timely reporting of abnormal findings ensures patient safety and prevents readmission.

⚽ Encouraging communication promotes adherence to discharge instructions and recovery plan.

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Answer 9

Correct Answers:

"The client has been putting pillows behind the knees."

Rationale :

"The client has been putting pillows behind the knees."

🌸 Placing pillows behind the knees can increase the risk of venous stasis, which may lead to the formation of deep vein thrombosis (DVT) in older adults who are already post-operative and immobile.

🌸 Flexion at the knees reduces venous return from the lower extremities, impeding circulation and increasing clot risk.

🌸 Older adults are at higher risk for post-operative complications such as DVT due to reduced mobility and changes in vascular elasticity.

🌸 Antiembolic stockings are recommended to maintain proper circulation, but pillows behind the knees can counteract their benefits.

🌸 Monitoring for signs of DVT, such as calf swelling or pain, is essential in post-operative care.

🌸 Educating the patient and family about proper positioning can prevent complications and improve safety outcomes.

🌸 Correct positioning involves keeping the legs in neutral alignment, avoiding prolonged knee flexion.

🌸 Early intervention and education are key in preventing thromboembolic events following surgery in immobilized clients.

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Answer 10

Correct Answers:

Use suction pressure no higher than 120 to 150 mm Hg.

Rationale :

"Use suction pressure no higher than 120 to 150 mm Hg."

⚡ Suction Pressure Safety: Maintaining suction pressure between 120–150 mm Hg ensures effective removal of secretions without causing trauma to the tracheal mucosa.

⚡ Prevent Tissue Damage: Higher suction pressures can damage delicate respiratory tissues, leading to bleeding and increased risk of infection.

⚡ Optimize Oxygenation: Appropriate suction pressure helps maintain oxygenation during the procedure, minimizing hypoxia episodes.

⚡ Mucus Removal Efficiency: Controlled suction pressure effectively removes secretions without collapsing airway passages.

⚡ Patient Comfort: Using safe suction levels reduces coughing, gagging, and discomfort during the procedure.

⚡ Standard of Care: Guidelines from respiratory care protocols recommend staying within this suction range for nasotracheal suctioning.

⚡ Minimize Complications: Helps prevent bronchospasm, mucosal trauma, and hypoxemia, which can occur with excessive pressure.

⚡ Consistent Monitoring: Nurses should monitor patient response while suctioning to adjust the technique if adverse signs occur.

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QLexNursing

1 :
A client has a blood sodium level of 128 mEq/L (136–145 mEq/L). Which finding will the nurse expect for the client?

2 :
The nurse finished teaching a client to use a cane. Which statement by the client indicates understanding of the instructions?

3 :
A sequential compression sleeve device was applied to a client after surgery. Which would the nurse state during teaching?

4 :
A client has been on the hospital unit for three days. Which finding would the nurse identify as a potential complication of prolonged immobility?

5 :
A nurse is caring for a client who is immobilized. Which support device will the nurse use to prevent plantar flexion contractures?

6 :
A nurse is preparing to transfer a client from lying in bed to sitting in a chair. When identifying the safest method of transfer, which is most important for the nurse to determine?

7 :
A nurse is caring for a client on complete bedrest. Which finding is a systemic effect of immobility? (Select 3 correct responses.)

8 :
A nurse is providing discharge teaching to a client following arthroscopic knee surgery. Which instruction will the nurse include in the client teaching?

9 :
An older client has been hospitalized for the past three days following abdominal surgery. Which statement by the nurse providing report is most concerning?

10 :
Which nursing action is indicated to perform nasotracheal suctioning?

QLexNursing

1 : A client has a blood sodium level of 128 mEq/L (136–145 mEq/L). Which finding will the nurse expect for the client?

2 : The nurse finished teaching a client to use a cane. Which statement by the client indicates understanding of the instructions?

3 : A sequential compression sleeve device was applied to a client after surgery. Which would the nurse state during teaching?

4 : A client has been on the hospital unit for three days. Which finding would the nurse identify as a potential complication of prolonged immobility?

5 : A nurse is caring for a client who is immobilized. Which support device will the nurse use to prevent plantar flexion contractures?

6 : A nurse is preparing to transfer a client from lying in bed to sitting in a chair. When identifying the safest method of transfer, which is most important for the nurse to determine?

7 : A nurse is caring for a client on complete bedrest. Which finding is a systemic effect of immobility? (Select 3 correct responses.)

8 : A nurse is providing discharge teaching to a client following arthroscopic knee surgery. Which instruction will the nurse include in the client teaching?

9 : An older client has been hospitalized for the past three days following abdominal surgery. Which statement by the nurse providing report is most concerning?

10 : Which nursing action is indicated to perform nasotracheal suctioning?

1 :
A client has a blood sodium level of 128 mEq/L (136–145 mEq/L). Which finding will the nurse expect for the client?

2 :
The nurse finished teaching a client to use a cane. Which statement by the client indicates understanding of the instructions?

3 :
A sequential compression sleeve device was applied to a client after surgery. Which would the nurse state during teaching?

4 :
A client has been on the hospital unit for three days. Which finding would the nurse identify as a potential complication of prolonged immobility?

5 :
A nurse is caring for a client who is immobilized. Which support device will the nurse use to prevent plantar flexion contractures?

6 :
A nurse is preparing to transfer a client from lying in bed to sitting in a chair. When identifying the safest method of transfer, which is most important for the nurse to determine?

7 :
A nurse is caring for a client on complete bedrest. Which finding is a systemic effect of immobility? (Select 3 correct responses.)

8 :
A nurse is providing discharge teaching to a client following arthroscopic knee surgery. Which instruction will the nurse include in the client teaching?

9 :
An older client has been hospitalized for the past three days following abdominal surgery. Which statement by the nurse providing report is most concerning?

10 :
Which nursing action is indicated to perform nasotracheal suctioning?