A nurse is performing passive range of motion (ROM) and splinting on an at-risk patient. Which finding will indicate goal achievement for the nurse's action?
a. Prevention of atelectasis
b. Prevention of renal calculi
c. Prevention of pressure ulcers
d. Prevention of joint contractures
ANS: D
Goal achievement for passive ROM is prevention of joint contractures. Contractures develop in joints not moved periodically through their full ROM. ROM exercises reduce the risk of contractures. Researchers noted that prompt use of splinting with prescribed ROM exercises reduced contractures and improved active range of joint motion in affected lower extremities. Deep breathing and coughing and using an incentive spirometer will help prevent atelectasis. Adequate hydration helps prevent renal calculi and urinary tract infections. Interventions aimed at prevention of pressure ulcers include positioning, skin care, and the use of therapeutic devices to relieve pressure.
You might also like to view...
A client is prescribed sumatriptan (Imitrex) for the treatment of migraine headache. Which client statement would indicate a need for additional teaching from the nurse?
A) "I use this to prevent migraines." B) "I take this when I get a headache." C) "It constricts the blood vessels in my head." D) "It alleviates my sensitivity to light and sound."
The client experiences nausea and vomiting soon after chemotherapy treatments. What is the best action by the nurse?
1. Administer a sleeping medication during chemotherapy. 2. Increase fluid intake to flush the kidneys prior to chemotherapy. 3. Administer an antiemetic 1–2 hours before chemotherapy. 4. Restrict food on the day the client receives chemotherapy.
A parent was recently hospitalized with severe depression. Family members say, "We're falling apart. Nobody knows what to expect, who should make decisions, or how to keep the family together."
Which interventions should the nurse use when working with this family? Select all that apply. a. Help the family set realistic expectations. b. Provide empathy, acceptance, and support. c. Empower the family by teaching problem solving. d. Negotiate role flexibility amongst family members. e. Focus planning on the family rather than on the patient.
The nurse is collaborating with the dietitian about a patient with a Stage III pressure ulcer. Which nutrient will the nurse most likely increase after collaboration with the dietitian?
a. Fat b. Protein c. Vitamin E d. Carbohydrate