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 B

Explanation

A. Determine when each client last received pain medication is an important step in managing pain, but it does not address the immediate need to evaluate the severity of the clients' pain. Knowing when they last received pain medication can help with medication timing but should follow a thorough assessment.

B. Evaluate both clients' pain using a standardized pain scale is the most appropriate first action. This allows the nurse to assess the severity of each client’s pain and prioritize which client requires more immediate attention. Pain severity, rather than timing of medication, should guide the nurse's intervention.

C. Provide nonpharmacologic pain management interventions can be helpful, but it does not address the immediate need for assessing and addressing the severity of pain. Nonpharmacologic interventions can be used as an adjunct but should not replace proper assessment and pharmacologic management if necessary.

D. Prepare both clients' medication and take to them at once could lead to a delay in addressing the most severe pain. It is important to assess pain levels first to prioritize care, as one client may require medication sooner than the other.

A. Verify client's identification by scanning the barcode on the armband. B. Reconcile the medication to be administered with the initial client prescription. C. Remove the medication from the unit dose packaging while verifying the dose. D. Scan the medication barcode to document administration on the eMAR.

Correct Answer is A

Explanation

A. Verify client's identification by scanning the barcode on the armband is correct because verifying the client’s identity is the next step after accessing the eMAR. This ensures that the right medication is given to the right client, following the “rights” of medication administration.

B. Reconcile the medication to be administered with the initial client prescription is important but should already have been completed during the medication preparation and verification process.

C. Remove the medication from the unit dose packaging while verifying the dose is part of the preparation process but occurs after confirming the client’s identity.

D. Scan the medication barcode to document administration on the eMAR is done after verifying the client’s identity and ensuring the medication is correct. It is not the immediate next step after logging into the eMAR.

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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

Two clients ring their call lights simultaneously requesting pain medication. Which action should the nurse implement first?

Correct Answer is B

Explanation

When administering a new medication to a client, the nurse logs in the electronic medication administration record (eMAR). Which action should the nurse take next?

Correct Answer is A

Explanation

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