A nurse is caring for a client who has right-sided hemiplegia following a stroke. Which of the following actions should the nurse take to assist the client from the bed to a wheelchair?
Reach under the client's arms to pull them up.
Pivot the client on the foot closest to the chair.
Place the wheelchair on the left side of the client.
Ask the client to reach around the nurse's neck for support.
The Correct Answer is C
When transferring a client with unilateral weakness, such as hemiplegia, safety and biomechanical principles are paramount. The goal is to maximize the client’s independence by utilizing their stronger side and minimizing the risk of falls for both the patient and the nurse.
Rationale:
A. "Reach under the client's arms to pull them up" is an incorrect action. This maneuver is ergonomically unsafe for the nurse and can cause injury to the client’s shoulders, particularly the affected shoulder, which may have decreased stability or tone.
B. "Pivot the client on the foot closest to the chair" is an incorrect action. The client should be instructed to pivot on their stronger (unaffected) foot. Pivoting on the weaker foot can lead to instability and an increased risk of the client’s knee buckling.
C. "Place the wheelchair on the left side of the client" is the correct action. Because the client has right-sided hemiplegia, their left side is their stronger side. Placing the wheelchair on the client's stronger side allows them to lead the transfer with their stronger leg and arm, providing the necessary support and control during the movement.
D. "Ask the client to reach around the nurse's neck for support" is an incorrect action. This is unsafe for the nurse and the client. The client should be instructed to place their hands on the nurse's waist or shoulders (or the armrests of the chair), while the nurse maintains a safe, stable grip on the transfer belt.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Urinary incontinence increases the risk of skin breakdown due to prolonged exposure of the skin to moisture, enzymes, and irritants found in urine. This can lead to incontinence-associated dermatitis, maceration, and secondary infection if not properly managed. Nursing care focuses on maintaining skin integrity through frequent cleansing, moisture control, and protective barriers. Preventive skin care is essential to reduce complications and promote comfort.
Rationale:
A. Keeping the client’s skin moist is incorrect because excess moisture increases skin maceration and breakdown. Prolonged exposure to urine weakens the skin barrier and increases susceptibility to irritation and infection. Skin should be kept clean and dry to maintain integrity.
B. Applying barrier cream to cleansed skin is correct because it forms a protective layer that shields the skin from moisture and irritants. In clients with conditions such as Urinary incontinence, barrier products help prevent dermatitis and preserve skin integrity. This is a key intervention in incontinence care.
C. Applying cornstarch is not recommended because it can cake on moist skin and potentially promote microbial growth. It does not provide an effective moisture barrier and may worsen skin irritation. Modern barrier creams are preferred for protection.
D. Rinsing the skin with hot water is inappropriate because hot water can damage the skin barrier and increase dryness and irritation. Warm water is recommended instead to gently cleanse without causing additional skin injury. Excessive heat may further compromise already vulnerable skin.
Correct Answer is B
Explanation
Postoperative calf pain in a client 2 days after surgery raises concern for possible venous thromboembolism, particularly deep vein thrombosis (DVT). Reduced mobility, surgical stress, and postoperative hypercoagulability increase the risk of clot formation in the lower extremities. If a clot dislodges, it may travel to the lungs and cause a life-threatening pulmonary embolism, which can first present with subtle respiratory changes. Monitoring oxygenation is essential for early detection of respiratory compromise associated with clot migration.
Rationale:
A. Instructing the client to massage the calf is contraindicated because it may dislodge a thrombus if a deep vein clot is present. This increases the risk of embolization to the lungs, leading to pulmonary embolism. Suspected DVT requires immobilization of the affected limb rather than manipulation or massage.
B. Monitoring pulse oximetry is appropriate because a decrease in oxygen saturation may indicate possible pulmonary embolism, a serious complication of suspected DVT. Early hypoxemia can occur even before obvious respiratory symptoms appear. Continuous assessment of oxygenation helps detect deterioration early in a client with suspected thromboembolic disease.
C. Applying a cold compress to the calf is not appropriate in suspected deep vein thrombosis. Cold therapy may provide comfort in musculoskeletal injuries but does not address clot-related pathology. The priority is to prevent clot dislodgement and monitor for systemic complications rather than local symptom relief.
D. Maintaining the leg in a dependent position is contraindicated because it can increase venous stasis and worsen thrombus formation. The affected limb should typically be kept immobile and elevated if appropriate, depending on provider guidance. Dependent positioning increases hydrostatic pressure and may exacerbate swelling and pain.
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