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 B

Explanation

A reason:

A blood pressure of 138/90 is elevated but not immediately life-threatening. It is important to monitor, but it is not the highest priority in this situation.

B reason:

A heart rate of 110 beats per minute is the most concerning and should be addressed first. Tachycardia can indicate pain, fever, or other underlying issues that need prompt attention.

C reason:

An O2 Sat of 95% is within normal limits and is not an immediate concern compared to the other vital signs presented.

D reason:

A temperature of 38°C indicates a fever, which needs to be addressed, but the elevated heart rate takes priority as it can have more immediate implications for the client's condition.

A. Blood pressure increases with age. B. Blood pressure decreases after eating food. C. Blood pressure is usually highest on arising in the morning. D. Blood pressure tends to be higher in smokers. E. Hormones can affect blood pressure as seen in women after menopause

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

Explanation

A reason:

Blood pressure increases with age because blood vessels naturally become less flexible and more resistant to blood flow as we age. This resistance can cause an increase in blood pressure. Additionally, lifestyle factors and accumulation of health issues over time contribute to higher blood pressure in older adults.

B reason:

Blood pressure does not typically decrease after eating food. Instead, it may temporarily increase due to the body’s metabolic response to digestion and absorption of nutrients. Some individuals may experience postprandial hypotension, but this is not a common occurrence.

C reason:

Blood pressure is usually highest on arising in the morning due to the body's natural circadian rhythm. The release of certain hormones like cortisol and adrenaline upon waking can cause an increase in blood pressure. This phenomenon is known as the "morning surge."

D reason:

Blood pressure tends to be higher in smokers because nicotine and other chemicals in cigarettes cause vasoconstriction, which increases blood pressure. Chronic smoking can also lead to long-term damage to the cardiovascular system, further elevating blood pressure.

E reason:

Hormones can affect blood pressure, especially in women after menopause. The decline in estrogen levels can lead to increased blood pressure due to changes in vascular health and metabolism. Hormonal fluctuations throughout a woman's life can also influence blood pressure.

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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

The nurse is caring for a client who presented to the emergency room with BP of 138/90, HR of 110, O2 Sat of 95%, Temp of 38°C, and abdominal pain level of 7/10. Which of the above vital signs would the nurse address first?

Correct Answer is B

Explanation

The nurse instructor is teaching student nurses about the factors that may affect a patient's blood pressure. Which statements accurately describe these factors? Select all that apply.

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

Explanation

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