A nurse is preparing to transfer a patient who can bear weight on one leg from the bed to a chair. After securing a safe environment, what should the nurse do next?

Rock the patient up to a standing position.

Pivot on the foot that is the farthest from the chair.

Assess the patient for orthostatic hypotension.

Apply a gait belt to the patient.

Answer and Explanation

The Correct Answer is C

The correct answer is Choice C.

Choice C rationale: Assessing the patient for orthostatic hypotension is crucial because patients who can only bear weight on one leg may have compromised balance and stability. Orthostatic hypotension, or a sudden drop in blood pressure upon standing, could lead to dizziness or fainting, increasing the risk of falls and injury. Identifying this condition before transferring the patient ensures appropriate interventions can be taken to maintain safety and prevent accidents. The nurse can then apply necessary precautions such as additional support or slow, gradual position changes to minimize the risk.

Choice A rationale: Rocking the patient up to a standing position might help initiate the transfer, but it’s not the immediate priority after securing a safe environment. Ensuring the patient's stability and monitoring their vital signs, especially for orthostatic hypotension, is essential before attempting any movement.

Choice B rationale: Pivoting on the foot that is the farthest from the chair is part of the transfer technique, but it should only be performed after confirming the patient is stable and not at risk of orthostatic hypotension. Proper assessment precedes this step to prevent potential falls.

Choice D rationale: Applying a gait belt to the patient is important for safe transfer, but again, this step follows the assessment of the patient's condition. The gait belt is an aid for the transfer process, but its effectiveness relies on the patient's ability to stand without becoming dizzy or faint.

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Correct Answer is A

Explanation

Choice A rationale

Granulation tissue covering the wound bed is a positive sign of wound healing. Granulation tissue is a key component of the wound healing process, typically forming during the proliferation phase. It consists of new connective tissue and tiny blood vessels that develop in the wound bed as part of the body’s response to injury. Therefore, the presence of granulation tissue covering the wound bed indicates an improvement in the patient’s condition.

Choice B rationale

Slight erythema at the wound edges could be a sign of inflammation or infection. Erythema, or redness of the skin, is often associated with inflammation or infection. While it can be a normal part of the healing process, persistent or increasing erythema could indicate a problem such as infection or irritation. Therefore, slight erythema at the wound edges does not necessarily indicate an improvement in the patient’s condition.

Choice C rationale

The surrounding tissue being warm to touch could be a sign of inflammation or infection. When skin feels hot to the touch, it often means that the body’s temperature is hotter than normal. This can happen due to an infection or an illness, but it can also be caused by an

environmental situation that increases body temperature. Therefore, the surrounding tissue being warm to touch does not necessarily indicate an improvement in the patient’s condition.

Choice D rationale

The patient reporting pain as a 2 on a scale from 0 to 10 could indicate that the patient’s pain is minor. On a pain scale, a score of 2 usually indicates minor pain. However, pain is a subjective experience and can vary greatly among individuals. Therefore, while a lower pain score generally suggests less severe pain, it does not necessarily indicate an improvement in the patient’s overall condition.

A. Group discussions B. Query answer meetings C. Practice sessions D. Role play

Correct Answer is D

Explanation

Choice A rationale

Group discussions can be beneficial for sharing experiences and learning from others, but they do not provide the hands-on, practical experience that is characteristic of the psychomotor learning domain.

Choice B rationale

-answer meetings can be useful for clarifying doubts and enhancing understanding, but they do not offer the opportunity for physical manipulation of objects or execution of procedures, which is central to psychomotor learning.

Choice C rationale

Practice sessions can be an effective method for psychomotor learning as they allow for repeated performance of a skill. However, in the context of teaching adolescents with newly placed ostomies, role play might be more beneficial as it allows for the simulation of real-life scenarios and the practice of problem-solving skills in a safe and controlled environment.

Choice D rationale

Role play is a method that falls under the psychomotor domain of learning. It involves acting out scenarios and provides an opportunity for hands-on practice and learning. In the context of adolescents with newly placed ostomies, role play can help them practice self-care tasks related to ostomy management in a safe and supportive environment.

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A nurse is preparing to transfer a patient who can bear weight on one leg from the bed to a chair. After securing a safe environment, what should the nurse do next?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is A

Explanation

A nurse is planning a teaching session for a group of adolescents who each recently had an ostomy surgically placed. Which of the following methods should the nurse use as a psychomotor approach to learning?

Correct Answer is D

Explanation

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