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 C
Explanation
Choice A rationale
A temperature of 36.5°C is considered normal.
Choice B rationale
A temperature of 37.5°C is slightly elevated but still within the normal range.
Choice C rationale
A temperature of 38.5°C is considered a fever. Given the client’s symptoms of a productive cough with thick yellow sputum and abnormal breath sounds, this could indicate an infection such as pneumonia, which would likely cause a fever.
Choice D rationale
A temperature of 39.5°C is a high fever and could indicate a severe infection. However, the client’s symptoms are more consistent with a moderate fever.
Correct Answer is A
Explanation
The nurse’s priority action should be to determine the reasons why the client is refusing to use the incentive spirometer. Understanding the client’s concerns or fears can help the nurse address them and encourage the client to participate in this important aspect of postoperative care.
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