A client receives a diagnosis of right-sided paralysis. Which action does the nurse take when assisting the client in transferring from the bed to the wheelchair?

Sits client on the side of the bed and assists the client to stand on right leg

Rolls client to the right side and raises head to sit client on the side of the bed

Lays client ﬂat on the left side and has client stand at the side of the bed

Stands client from the side of the bed on the left leg and pivots client to the chair

Answer and Explanation

The Correct Answer is D

This is because the client has right-sided paralysis and will not be able to bear weight on their right leg. By standing on their left leg and pivoting to the chair, the client can safely transfer from the bed to the wheelchair with the assistance of the nurse.

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Correct Answer is C

Explanation

Negligence is a failure to act in a reasonable and prudent manner that results in harm or injury to another person. In option c), the nurse did not exercise reasonable care in ensuring that the medication was given to the correct patient, which resulted in harm to the wrong patient.

The other options (a, b, and d) do not involve a failure to act in a reasonable and prudent manner that caused harm or injury to the client. In option a), the nurse provided written and verbal instructions, but the client did not follow them, which is beyond the nurse's control.

In option b), the nurse made an error in documenting the ﬂuid count, which is a documentation error, not negligence. In option d), the nurse acted appropriately by calling the healthcare provider to change the client's behavior, and the situation does not involve negligence.

A. Places the client in Trendelenburg position B. Stays with the client and calls for assistance C. Place sterile moistened ABD pads over the wound D. With a sterile glove, attempts to reinsert the intestine into the abdominal cavity E. Encourages the client to drink ﬂuids F. Obtains the client's vital signs

Correct Answer is ["B","C"]

Explanation

The client has a complication of the surgical wound dehiscence, which occurs when the wound edges separate or pull apart. In this case, a portion of the intestine is protruding from the wound bed, indicating a wound evisceration. It is a medical emergency that requires prompt intervention to prevent complications such as infection, hemorrhage, or sepsis.

The nurse should first stay with the client and call for assistance to notify the healthcare provider or surgical team immediately. The surgical team will need to evaluate the wound and perform emergency surgery if necessary.

The nurse should then place sterile moistened ABD pads over the wound to prevent the intestine from drying out and to protect the protruding tissue from further injury or infection.

Placing the client in Trendelenburg position (a) is contraindicated as it can cause a shift of abdominal contents and further worsen the condition. Attempting to reinsert the intestine into the abdominal cavity (d) is also not within the scope of practice for the nurse and can cause harm to the client. Encouraging the client to drink ﬂuids (e) or obtaining the client's vital signs (f) are not the priority actions in this situation.

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A client receives a diagnosis of right-sided paralysis. Which action does the nurse take when assisting the client in transferring from the bed to the wheelchair?

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Naxlex Comprehensive Predictor Exams

In which situation is the nurse determined to be negligent?

Correct Answer is C

Explanation

Correct Answer is ["B","C"]

Explanation

While the nurse prepares an injection for a client, the needle cap falls on the ﬂoor. Which action indicates that the injection will be sterile?

The nurse delegated vital signs for a group of patients to the unlicensed assistive personnel (UAP). Which client condition would prohibit having a rectal temperature taken by the UAP?

The nurse omits to document an assessment finding that resulted in a significant client injury. For which legal issue does the nurse need to prepare?

The nurse provides care for a client with a poor appetite. Which action does the nurse take to enhance the client's nutritional intake?

A client receives a diagnosis of right-sided paralysis. Which action does the nurse take when assisting the client in transferring from the bed to the wheelchair?

A bed-bound chart has a prescription for routine urinalysis. In which way does the nurse obtain the urine sample for the laboratory?

A family member tells the nurse, "I overheard a caregiver threaten my uncle." The family member said the caregiver remarked, "If you don't learn to calm down, I will have to restrain you." Based on this information, which criminal oﬀense does the nurse communicate to the nurse manager?