A nurse is assisting a client who has generalized weakness to move from the bed to a wheelchair. What actions should the nurse take?
Lock the wheels of the bed and the wheelchair.
Elevate the bed to a position of comfort for the nurse.
Get the help of several staff members to lift the client.
Place the wheelchair at a 90° angle to the bed.
The Correct Answer is B
Choice A rationale
Locking the wheels of the bed and the wheelchair is an important safety measure when assisting a client to move from the bed to a wheelchair. However, this action alone is not sufficient. The nurse also needs to ensure the client’s safety during the transfer by using proper body mechanics and providing adequate support.
Choice B rationale
Elevating the bed to a position of comfort for the nurse is the correct action. This helps to ensure that the nurse can maintain proper body mechanics during the transfer, reducing the risk of injury to both the nurse and the client.
Choice C rationale
Getting the help of several staff members to lift the client is not typically necessary when transferring a client with generalized weakness from the bed to a wheelchair. With proper positioning and technique, one nurse can often safely assist the client with this type of transfer.
Choice D rationale
Placing the wheelchair at a 90° angle to the bed is not the recommended position when transferring a client from the bed to a wheelchair. Instead, the wheelchair should be positioned parallel to the bed or at a slight angle.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale
Slough, which is a layer of yellowish, dead tissue that can develop on the surface of a wound, is not a defining characteristic of a stage 3 pressure ulcer.
Choice B rationale
Persistent reddening of the skin is typically associated with a stage 1 pressure ulcer, not a stage 3. In a stage 1 pressure ulcer, the skin remains intact but may be red and may not blanch (lose color briefly) when you press your finger on it.
Choice C rationale
A stage 3 pressure ulcer involves full-thickness skin loss that appears as a deep crater. The ulcer may extend into the subcutaneous tissue layer, but not through it to the underlying
muscle or bone. This description matches the statement in Choice C, making it the correct answer.
Choice D rationale
A fluid-filled area under the skin could potentially indicate a blister or a stage 2 pressure ulcer, not a stage 3. In a stage 2 pressure ulcer, the outer layer of skin (epidermis) and part of the underlying layer of skin (dermis) are damaged or lost.
Correct Answer is C
Explanation
Choice A rationale
Rapid respirations that are unusually deep and regular are not indicative of Cheyne-Stokes respirations. Cheyne-Stokes respirations are characterized by periods of apnea followed by gradually increasing then decreasing tidal volumes until another period of apnea.
Choice B rationale
An inability to breathe without dyspnea unless sitting upright is not indicative of Cheyne- Stokes respirations. This is more characteristic of orthopnea, which is commonly seen in conditions like heart failure.
Choice C rationale
Breathing ranging from very deep to very shallow with periods of apnea is indicative of Cheyne-Stokes respirations. This pattern of breathing is often seen in conditions such as heart failure, stroke, or brain damage.
Choice D rationale
Shallow breathing alternating with periods of apnea is not indicative of Cheyne-Stokes respirations. In Cheyne-Stokes respirations, the pattern of breathing includes periods of apnea followed by a gradual increase and then decrease in the depth of respirations.
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