A nurse is preparing to transfer a client from lying in bed to sitting in a chair. When identifying the safest method of transfer, which of the following is most important for the nurse to determine?

The client's height

The client's ability to communicate

The client's current weight-bearing status

The type of equipment used in previous transfers

Answer and Explanation

The Correct Answer is C

A. Knowing the client's height can be helpful for ergonomic considerations, but it is not critical for the transfer process.

B. The client's ability to communicate is important for understanding their needs and preferences but does not directly impact the physical safety of the transfer.

C. The client's current weight-bearing status is crucial to determine the safest method of transfer. If the client cannot bear weight, additional assistance or equipment may be necessary to prevent falls or injury.

D. While knowing the type of equipment used in previous transfers can provide insight, it is secondary to understanding the client's current physical capabilities and needs.

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Correct Answer is A

Explanation

A. Using attentive listening with the client demonstrates the principle of presence by showing that the nurse is fully engaged and invested in the client's experience, fostering a collaborative relationship.

B. While focusing on the client’s present circumstances is important, the personal stories shared by clients can provide context and enhance understanding, so limiting this aspect is not ideal.

C. Offering personal thoughts and beliefs can shift the focus away from the client and is generally not appropriate in professional communication.

D. While verbalizing understanding is a supportive action, it does not fully encapsulate the principle of presence, which emphasizes active engagement and listening.

A. Check residual volume every 4 to 6 hr. B. Observe client's respiratory status. C. Elevate the head of the client's bed 30° to 45°. D. Monitor intake and output every 8 hr.

Correct Answer is C

Explanation

A. Checking residual volume is important for assessing tolerance to feedings, but it is not the priority action to prevent complications related to decreased consciousness.

B. Observing the client’s respiratory status is crucial but not the priority action related to enteral feedings.

C. Elevating the head of the client's bed 30° to 45° is the priority action, as it reduces the risk of aspiration during enteral feeding, which is a significant concern for clients with decreased consciousness.

D. Monitoring intake and output is important for overall assessment but is not the immediate priority in this context.

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A nurse is preparing to transfer a client from lying in bed to sitting in a chair. When identifying the safest method of transfer, which of the following is most important for the nurse to determine?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is using the communication principle of presence when establishing a collaborative relationship with a client. Which of the following actions should the nurse take?

Correct Answer is A

Explanation

A nurse is planning care for a client who has a decreased level of consciousness. The client is receiving continuous enteral feedings via a gastrostomy tube due to an inability to swallow. Which of the following is the priority action by the nurse?

Correct Answer is C

Explanation

The nurse is preparing a medication for a client and observes the date of expiration on the vial occurred 2 months ago. Which of the following actions should the nurse take?

A nurse is caring for a client who is unconscious and has a breathing pattern characterized by alternating periods of hyperventilation and apnea. The nurse should document that the client has which of the following respiratory alterations?

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A nurse is instructing a group of clients regarding nutrition. The teaching should state that which of the following groups of foods contains the highest level of carbohydrates?

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