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.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is B

Explanation

A. Report any change in urine color is not a primary intervention in palliative care for this client. While monitoring urine output is important in assessing hydration status, it does not directly address the client's comfort, which is a key goal in palliative care.

B. Keep mucous membranes moist is a critical intervention for this client. Mouth breathing and the refusal of fluids can lead to dry mucous membranes, causing discomfort. Regular oral care using swabs or rinses can alleviate dryness, improving the client's comfort and quality of life.

C. Record the client's daily weight is unnecessary in this situation. Monitoring weight is typically relevant for clients whose fluid balance or nutritional status is being managed, which is not a focus in palliative care for a terminally ill client.

D. Maintain in high Fowler's position is not the priority in this scenario. While positioning may be adjusted to support breathing, the focus should remain on comfort, such as alleviating the dryness associated with mouth breathing.

A. Reduce the stimuli in the area before continuing the teaching. B. Reassure the client that the skill is not difficult to learn. C. Provide the client with step-by-step written instructions. D. Demonstrate the skill, speaking slowly and using simple terms.

Correct Answer is A

Explanation

A. Reduce the stimuli in the area before continuing the teaching is the best action. Sensory overload can interfere with a client's ability to learn effectively. By reducing distractions and environmental stimuli, the nurse can create a more conducive learning environment.

B. Reassure the client that the skill is not difficult to learn may be helpful, but it does not address the immediate issue of sensory overload. The client needs to be in an environment where they can focus and process information before reassurance is effective.

C. Provide the client with step-by-step written instructions may be helpful later, but in the context of sensory overload, the priority is to first reduce the stimuli. Written instructions can be given once the client is in a calmer state.

D. Demonstrate the skill, speaking slowly and using simple terms is a helpful teaching strategy, but if the client is experiencing sensory overload, the first step should be to reduce the environmental stimuli. Once the environment is conducive to learning, the nurse can proceed with demonstrating the skill.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The palliative care nurse receives a consult for a terminally ill client in the intensive care unit (ICU). The client is weak, mouth breathing, and refusing anything to eat or drink. Which intervention should the nurse include in the plan of care?

Correct Answer is B

Explanation

While teaching a client how to perform a skill, the nurse determines that the client is experiencing sensory overload and is unable to learn effectively. Which action should the nurse implement?

Correct Answer is A

Explanation

The healthcare provider prescribes streptomycin 200 mg intramusculary every 12 hours. The vial is labeled, "Streptomycin 1 gram/2.5 mL". How many milliliters should the nurse administer? (Enter numerical value only. (If rounding is required, round to the nearest tenth.)

The nurse is caring for a client who is overweight and easily becomes diaphoretic. In response to this finding, which assessment(s) should the nurse include while assisting the client with personal care? Select all that apply.

The nurse is administering an intradermal (ID) injection to a client. Which action should the nurse take?

A client with fluid volume overload is admitted to the hospital for diuresis. Which assessment should the nurse perform to evaluate the client's fluid balance?

A client on a mechanical soft diet is experiencing constipation and asks the nurse for a glass of prune juice. After auscultating decreased bowel sounds, which action should the nurse implement?

The nurse educator is conducting a class for unlicensed assistive personnel (UAP). Which action indicates that a UAP understands gloving procedures?

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?