What is the primary purpose of repositioning a patient who is immobile?

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Question 1 of 5

What is the primary purpose of repositioning a patient who is immobile?

Correct Answer: A

Rationale: Repositioning an immobile patient primarily aims to prevent pressure ulcers by relieving pressure on skin over bony areas, like the sacrum or heels, and enhancing blood flow. Prolonged immobility risks tissue breakdown due to constant compression, making regular movement a cornerstone of preventive care in nursing. While shifting positions can secondarily support joint mobility, this isn't the main goal specific exercises target that more effectively. Building muscle strength requires active effort beyond repositioning, and though respiratory benefits may occur, they're addressed through targeted interventions like breathing exercises. This focus on skin integrity reflects nursing's priority to mitigate a common, severe complication of immobility, ensuring patient safety and comfort through proactive care.

Question 2 of 5

A nurse is caring for a client receiving high-flow oxygen therapy via a noninvasive positive pressure ventilation (NPPV) device. What is an important nursing intervention for this client?

Correct Answer: C

Rationale: Providing frequent oral care (C) is key with NPPV (e.g., CPAP/BiPAP), as high-flow air dries the mouth, risking sores or discomfort. Q4h SpO2 (A) isn't specific to NPPV. Q15min RR (B) is excessive. 1-2 L/min (D) doesn't apply to NPPV. Oral care enhances comfort, per critical care standards, vital for compliance.

Question 3 of 5

The nurse is to administer digoxin (Lanoxin) elixir to a 6-month-old with a congenital heart defect. The nurse auscultates an apical pulse rate of 100. The nurse should:

Correct Answer: B

Rationale: For a 6-month-old, an apical pulse of 100 beats per minute falls within the normal range (80-150 bpm), indicating it's safe to administer digoxin, a cardiac glycoside for heart defects, without delay. Recording and calling the physician or holding the dose isn't warranted unless the rate drops below 90-100 bpm (per pediatric guidelines). Rechecking post-administration isn't standard unless symptoms arise. Nurses document and proceed, ensuring timely therapy while monitoring for toxicity signs like bradycardia later.

Question 4 of 5

A 5-month-old infant is admitted to the ER with a temperature of 103.6°F and irritability. The mother states that the child has been listless for the past several hours and that he had a seizure on the way to the hospital. A lumbar puncture confirms a diagnosis of bacterial meningitis. The nurse should assess the infant for:

Correct Answer: B

Rationale: Tenseness of the anterior fontanel is a key sign of bacterial meningitis in a 5-month-old, indicating increased intracranial pressure from infection, alongside fever, irritability, and seizures. Periorbital edema isn't typical, a positive Babinski is normal at this age, and a negative scarf sign relates to tone, not pressure. Nurses assess this bulging fontanel urgently, as it signals worsening inflammation, guiding immediate antibiotic and supportive care to prevent brain damage or death in this critical condition.

Question 5 of 5

The nurse is preparing to administer regular insulin to a client with type 1 diabetes. Before administering the insulin, the nurse should:

Correct Answer: A

Rationale: Rotating the vial between hands mixes regular insulin gently, ensuring even suspension without denaturing it warming, shaking, or large needles risk potency loss or tissue damage. Nurses use this technique, confirming clarity, for safe, effective glycemic control in type 1 diabetes.

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