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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Free Nursing Study Resources

Correct Answer is ["A","B","D","E"]

Explanation

A. Around the nostrils is a common area for skin damage when using a nasal cannula. The constant pressure and friction from the cannula tubing can cause irritation or breakdown around the nostrils.

B. Bridge of the nose is another area to assess for skin damage. The nasal cannula can cause pressure ulcers or redness on the bridge of the nose, especially if the cannula is not properly positioned or if the client wears it for prolonged periods.

C. Across the forehead is not typically an area affected by a nasal cannula. The cannula does not usually make contact with the forehead, so skin damage in this area is unlikely.

D. Over the cheeks is an important area to assess. The tubing of the nasal cannula can rub against the skin on the cheeks, causing irritation or breakdown, particularly if the tubing is too tight or not positioned correctly.

E. Tops of the ears should also be observed. The tubing of the nasal cannula can cause pressure on the ears, especially if the tubing is looped behind the ears, leading to irritation or skin breakdown.

A. Call the nearest relative to come in and sign a new form. B. Call the healthcare provider (HCP) to have the procedure rescheduled. C. Have the client sign another form before surgery. D. Cross out the error and initial the consent form.

Correct Answer is B

Explanation

A. Call the nearest relative to come in and sign a new form is not the correct course of action. While family involvement may be important, the priority is to address the error in the consent form before proceeding with the surgery. The healthcare provider must be informed to ensure the correct procedure is performed.

B. Call the healthcare provider (HCP) to have the procedure rescheduled is the most appropriate action. The error in the consent form and the discrepancy between the consent and the surgical site marking must be addressed immediately to prevent a potentially catastrophic mistake. The healthcare provider will need to correct the error and ensure proper documentation before proceeding with surgery.

C. Have the client sign another form before surgery is not appropriate because the client has already been administered opioid medication, which may impair their ability to make informed decisions. The error in the consent form must be resolved with the healthcare provider before the client signs anything.

D. Cross out the error and initial the consent form is not an appropriate action. This could be seen as tampering with the document, and it does not resolve the issue of the incorrect surgical site. A new consent form must be signed after the error is corrected.

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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

Naxlex Comprehensive Predictor Exams

The nurse assesses a client who has a nasal cannula delivering oxygen at 2 liters/minute. To assess for skin damage related to the cannula, which areas should the nurse observe? Select all that apply.

Correct Answer is ["A","B","D","E"]

Explanation

Correct Answer is B

Explanation

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