A nurse is preparing to transfer a client who can bear weight on one leg from the bed to a chair. After securing a safe environment, which of the following actions should the nurse take next?
Rock the client up to a standing position.
Apply a gait belt to the client.
Pivot on the foot that is the farthest from the chair.
Assess the client for orthostatic hypotension.
The Correct Answer is D
Choice A rationale
Rocking the client to a standing position is an implementation step used during the actual transfer process. However, this should only occur after the nurse has ensured the client is physiologically stable enough to tolerate the change in position. Moving directly to this step without checking for hemodynamic stability could lead to a fall if the client experiences sudden dizziness. Safety protocols require assessment of vital signs and physical readiness before any manual handling or movement.
Choice B rationale
Applying a gait belt is a critical safety intervention that provides the nurse with a secure point of contact to assist with the client's balance and stability. While it is a necessary part of the transfer process, it is not the very next step after securing the environment. The nurse must first determine if the client can safely transition from a supine to a sitting position without experiencing adverse physiological symptoms that would make the transfer unsafe.
Choice C rationale
Pivoting on the foot farthest from the chair is a specific technical maneuver used to align the body correctly during the transfer to prevent musculoskeletal strain for both the nurse and the client. This action occurs at the end of the transfer sequence. Before reaching this point, the nurse must have already assessed the client's ability to stand and ensured that the client's blood pressure has stabilized following the change in their physical orientation.
Choice D rationale
Assessing for orthostatic hypotension is the priority next step because changing positions from supine to sitting or standing can cause a rapid drop in blood pressure. This drop occurs due to the gravitational pooling of blood in the lower extremities, which can lead to cerebral hypoperfusion and syncope. Identifying a decrease in systolic pressure ≥ 20 mmHg or diastolic pressure ≥ 10 mmHg is vital to prevent falls and ensure the client's safety during the transfer.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale
This explanation describes the mechanism of extended-release or sustained-release medications rather than enteric-coated tablets. Enteric coating is designed to resist dissolution in the acidic environment of the stomach and instead dissolve in the more alkaline environment of the small intestine. While crushing some medications causes a rapid release of the entire dose, the primary scientific concern with enteric-coated aspirin is the loss of gastric protection rather than the specific rate of systemic absorption.
Choice B rationale
Crushing an enteric-coated tablet does not destroy the active pharmacological ingredients of the aspirin itself; rather, it alters the physical delivery system. The aspirin remains chemically active but loses its protective outer layer. Claiming the ingredients are destroyed is scientifically inaccurate. The primary issue is that the medication will now exert its effects in the wrong part of the gastrointestinal tract, potentially leading to adverse local effects on the gastric mucosa that the coating was intended to prevent.
Choice C rationale
Suggesting that the nurse can crush enteric-coated medication and mix it with food is incorrect and potentially harmful. Crushing these tablets bypasses the intended safety mechanism, exposing the stomach lining to the irritating effects of aspirin. This can lead to gastritis or peptic ulcers. The nurse should never encourage altering a medication's form if it is specifically formulated with an enteric coat, as this violates standard pharmacological principles and safe medication administration practices for the client.
Choice D rationale
Enteric coating is specifically applied to aspirin to protect the gastric mucosa from direct irritation and to prevent the drug from being deactivated by stomach acid. If the coating is crushed, the aspirin is released prematurely in the stomach, significantly increasing the risk of gastric irritation, dyspepsia, and indigestion. Explaining this risk helps the client understand that the coating is a safety feature intended to prevent gastrointestinal discomfort and potential injury like ulcers or bleeding.
Correct Answer is A
Explanation
Choice A rationale
Erythema on pressure points is a primary indicator of stage 1 pressure injuries, signaling that the skin and underlying tissues are undergoing localized hypoxia due to compressed blood vessels. In an immobile client, redness that does not blanch indicates that microcirculation is compromised. The nurse must intervene immediately by implementing a repositioning schedule to restore blood flow and prevent the progression to full-thickness tissue necrosis.
Choice B rationale
A pulse strength of 2+ is considered a normal finding in an adult, indicating a brisk and palpable arterial flow. While immobility increases the risk of deep vein thrombosis due to venous stasis, a 2+ pulse suggests that the peripheral arterial circulation is currently adequate. The nurse should continue to monitor for other signs of vascular issues, but this specific finding does not require an immediate corrective intervention.
Choice C rationale
Although high fluid intake is encouraged to prevent renal calculi and constipation in immobile clients, an intake of less than 3,000 mL per day is not necessarily an emergency. Many adults maintain adequate hydration with 2,000 to 2,500 mL daily. Unless the client shows signs of dehydration, such as dark urine or poor skin turgor, this finding is less urgent than the signs of localized tissue ischemia seen in erythema.
Choice D rationale
Having a bowel movement every other day is often within the normal range for many healthy adults. While immobility significantly decreases gastrointestinal motility and increases the risk of constipation, a frequency of every 48 hours is not inherently pathological. The nurse should assess for stool consistency and abdominal distension, but a specific intervention is not required solely based on this frequency if the client remains comfortable.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.