A nurse is preparing to assist a client who can partially bear weight and is cooperative with transfer from the bed to a chair. Which of the following actions should the nurse take to maintain safety during the transfer?

Enlist help from another staff member

Avoid movements that twist the spine

Use a powered standing-assist lift

Adjust the bed to an appropriate height

Answer and Explanation

The Correct Answer is C

A reason:

Enlisting help from another staff member is important for safety, but it is not the most specific intervention for this scenario. Using a powered lift ensures a safer and more controlled transfer process.

B reason:

Avoiding movements that twist the spine is good practice for the nurse's safety, but it does not directly address the client's need for assistance during the transfer. Proper lifting techniques are important, but mechanical assistance is preferable for this situation.

C reason:

Using a powered standing-assist lift is the best option. It helps the client who can partially bear weight to transfer safely and reduces the risk of injury to both the client and the nurse. This equipment is designed specifically for such transfers.

D reason:

Adjusting the bed to an appropriate height is a necessary step to facilitate the transfer, but it is not sufficient on its own. Using a lift in addition to adjusting the bed height ensures maximum safety and efficiency during the transfer process.

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Correct Answer is C

Explanation

A reason:

The evaluation phase involves assessing the effectiveness of the interventions and care plan, rather than gathering initial information about potential allergies. Asking about allergies comes earlier in the process.

B reason:

The planning phase focuses on setting goals and determining interventions based on the assessment data. While allergies are considered during planning, the initial gathering of allergy information occurs earlier.

C reason:

The assessment phase is correct. This is when the nurse collects comprehensive data about the client’s health status, including potential allergies. Gathering this information during assessment helps to prevent adverse reactions and plan safe care.

D reason:

The implementation phase involves carrying out the interventions outlined in the care plan. By this stage, any allergies should already be identified and documented to ensure safe execution of the care plan.

A. Plain yogurt B. Lemon sherbet C. Carrot juice D. Cranberry juice

Correct Answer is D

Explanation

A reason:

Plain yogurt is not a clear liquid. It is considered part of a full liquid or soft diet and is not appropriate for the initial postoperative clear liquid diet.

B reason:

Lemon sherbet is not considered a clear liquid. It falls under a full liquid diet and is not suitable for the clear liquid diet phase.

C reason:

Carrot juice, though a liquid, is not clear. It contains pulp and particulates, making it unsuitable for a clear liquid diet.

D reason:

Cranberry juice is appropriate for a clear liquid diet. It is transparent and does not contain any solids, making it suitable for postoperative clients on a clear liquid diet.

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A nurse is preparing to assist a client who can partially bear weight and is cooperative with transfer from the bed to a chair. Which of the following actions should the nurse take to maintain safety during the transfer?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse in a clinic is interviewing a client who will undergo diagnostic testing. The nurse should ask about a client's potential allergies during which phase of the nursing process?

Correct Answer is C

Explanation

A nurse is caring for a client who is postoperative following abdominal surgery. The surgeon initially prescribes a clear liquid diet. Which of the following items should the nurse include on the client's lunch tray?

Correct Answer is D

Explanation

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