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 A

Explanation

A. Call the pharmacy to see which medications should be taken indicates a misunderstanding of discharge instructions. The client should already have a clear understanding of their prescribed medications before discharge, including dosage, timing, and purpose. This responsibility lies with the healthcare provider or nurse, not the pharmacy, and the nurse should provide additional clarification.

B. Verify that a follow-up appointment has been scheduled is appropriate and demonstrates that the client understands the importance of follow-up care to monitor recovery and address any complications.

C. Notify the healthcare provider (HCP) if a fever develops is a correct action, as fever may indicate infection, a common postoperative complication that requires prompt attention.

D. Use movement techniques taught by the physical therapists reflects proper understanding of postoperative mobility instructions, which are crucial for preventing complications such as blood clots and for supporting recovery.

A. Warm, dry skin with a fever of 100.0° F (37.8° C). B. 4+ pitting edema of both lower extremities. C. A Braden risk assessment scale rating score of ten. D. Hypoactive bowel sounds with infrequent bowel movements.

Correct Answer is C

Explanation

A. Warm, dry skin with a fever of 100.0° F (37.8° C) is not directly related to the need for frequent turning. A fever and warm, dry skin may indicate an infection or another underlying condition, but it does not prioritize the need for turning in the context of pressure injury prevention.

B. 4+ pitting edema of both lower extremities may indicate fluid retention, but it is not as directly related to the risk of developing pressure injuries. Although edema can impact skin integrity, the Braden scale score is a more reliable indicator for turning schedules to prevent pressure ulcers.

C. A Braden risk assessment scale rating score of ten is the most important factor in determining the turning schedule. A score of ten indicates a high risk for developing pressure ulcers, which is directly related to the need for frequent repositioning to relieve pressure and prevent skin breakdown.

D. Hypoactive bowel sounds with infrequent bowel movements may be a concern for gastrointestinal function, but it does not directly affect the turning schedule. The Braden scale score is a better indicator for deciding how often the client needs to be turned to prevent pressure injuries.

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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?

Nursing Test Bank

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