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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
The quality of pain is a subjective description of what the pain feels like to the patient. The statement “I feel a dull ache in my stomach” provides a description of the quality of the patient’s pain.
Correct Answer is A
Explanation
Choice A rationale
Pressing gently on the tragus of the ear after administering the medication can help the medication to reach the inner ear.
Choice B rationale
Packing a small piece of cotton deep into the patient’s ear canal is not recommended as it can cause damage to the ear.
Choice C rationale
Moving the patient’s auricle down and back towards their head is not necessary when administering otic medication.
Choice D rationale
Tilting the patient’s head backward for 5 minutes is not required when administering otic medication.
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.