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

The client’s symptoms of itching, anxiety, a flushed face, and hives after the initiation of a blood transfusion are indicative of an allergic reaction. These symptoms suggest that the client may be having a reaction to the transfused blood, which can occur if the client’s immune system reacts against the blood cells or other components of the transfused blood.

Choice B rationale

While some side effects can occur during a blood transfusion, the symptoms the client is experiencing are not normal side effects of the procedure. Normal side effects might include a slight fever or chills.

Choice C rationale

Although the client is experiencing anxiety, this is likely a symptom of the allergic reaction rather than an indication of an anxiety disorder.

Choice D rationale

Hypersensitivity to the IV gauge material is unlikely to cause the symptoms the client is experiencing. Hypersensitivity reactions to medical device materials are rare and would not typically cause systemic symptoms like itching and hives.

A. Insert the suction catheter while the patient is swallowing. B. Apply intermittent suction when withdrawing the catheter. C. Place the catheter in a location that is clean and dry for later use. D. Hold the suction catheter with their clean, non-dominant hand.

Correct Answer is B

Explanation

Choice A rationale

Inserting the suction catheter while the patient is swallowing is not the recommended technique for nasotracheal suctioning. This could cause discomfort and potentially lead to aspiration.

Choice B rationale

Applying intermittent suction when withdrawing the catheter is the correct technique for nasotracheal suctioning. This helps to remove secretions effectively while minimizing trauma to the nasal and tracheal mucosa.

Choice C rationale

Placing the catheter in a location that is clean and dry for later use is not a recommended practice. After suctioning, the catheter should be properly cleaned or disposed of to prevent infection.

Choice D rationale

Holding the suction catheter with their clean, non-dominant hand is not a recommended practice. The nurse should use clean gloves and proper hand hygiene when performing nasotracheal suctioning to prevent infection.

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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 caring for a patient who has a respiratory infection.What technique should the nurse use when performing nasotracheal suctioning for the patient?

Correct Answer is B

Explanation

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