A male client has right-sided hemiplegia following a left cerebrovascular accident (CVA). His sitting balance has improved, and he is now able to sit in a wheelchair. To assist the client in transferring from the bed to a wheelchair, which action should the nurse take?

Place the wheelchair on the client's left side.

Instruct the client to take slow, deep breaths while transferring.

Instruct the client to look at his feet.

Have the client put both arms around the nurse's neck for support.

Answer and Explanation

The Correct Answer is A

A. Place the wheelchair on the client's left side is the most appropriate action. Since the client has right-sided hemiplegia, the nurse should place the wheelchair on the client's left side to allow for easier transfer. The left side is the stronger side, and the client will be able to use this side to assist with the transfer.

B. Instruct the client to take slow, deep breaths while transferring may help with relaxation, but it is not the priority in this scenario. The focus should be on positioning and safety during the transfer.

C. Instruct the client to look at his feet is not advisable because it may disrupt the client's balance or lead to a fall. The client should focus on using the stronger side to assist with the transfer.

D. Have the client put both arms around the nurse's neck for support is not safe and could cause strain or injury to both the client and the nurse. The client should be instructed to use proper body mechanics and rely on the nurse for support during the transfer, but not in a way that could lead to injury.

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Correct Answer is C

Explanation

A. Prescription for ceftriaxone PO every 12 hours is not relevant in the initial "Situation" section of SBAR. This would fit better under the "Recommendation" or "Background" sections.

B. A 26-year-old client is part of the background information but does not immediately address the critical issue requiring attention.

C. Blood pressure is 80/48 mm Hg is the most urgent information and provides a clear reason for contacting the healthcare provider.

D. Admitted after a motor vehicle collision is part of the background and would follow the situation statement.

A. Turgor. B. Blood pressure. C. Weight. D. Lung sounds.

Correct Answer is C

Explanation

A. Turgor is not a reliable indicator of fluid balance in clients with fluid volume overload, as it is more commonly used to assess dehydration.

B. Blood pressure is affected by fluid volume but is not a direct or specific measure of fluid balance. Other factors, such as medication or underlying conditions, can influence blood pressure.

C. Weight is the most accurate and sensitive indicator of fluid balance. A change in weight directly correlates with fluid retention or loss, making it the preferred method for evaluating fluid balance.

D. Lung sounds can indicate fluid overload if crackles are present, but they are not a quantitative measure of fluid balance and do not provide ongoing assessment of fluid changes.

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A male client has right-sided hemiplegia following a left cerebrovascular accident (CVA). His sitting balance has improved, and he is now able to sit in a wheelchair. To assist the client in transferring from the bed to a wheelchair, which action should the nurse take?

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Naxlex Comprehensive Predictor Exams

The nurse notifies the healthcare provider related to client information using the Situation, Background, Assessment, Recommendation (SBAR) technique. Which information should the nurse provide first?

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Correct Answer is C

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