Ati Rn Fundamentals Online Practice 2023 B Questions And Answers 100% Verified A+ Guaranteed

A nurse is caring for a client who had a spinal cord injury and has paraplegia. The nurse is reviewing the client's medical record. Click to highlight the findings that require intervention by the nurse. To deselect a finding, click on the finding again. Client is repositioned every 2 hr. Passive range-of-motion exercises to lower extremities performed once each day. Feet warm. Pedal pulses 2+ bilaterally. Plantar flexion contractures noted bilaterally. Left heel with 1.3 cm x 1.3 cm (0.5 in x 0.5 in) area of nonblanchable erythema, skin intact. {Ans: Correct Answer: Client is repositioned every 2 hr The nurse should reposition the client every 2 hr to reduce the risk for skin breakdown. Therefore, this finding does not require intervention at this time. Passive range-of-motion exercises to lower extremities performed once each day The nurse should perform passive range-of-motion exercises to the client's lower extremities two to three times each day to reduce the risk for contractures. Plantar flexion contractures noted bilaterally The nurse should place a footboard at the end of the client's bed or apply foot boots to the client's feet to protect the client's heels and decrease the contractures. Left heel with 1.3 cm