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.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

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.

A. Assist the client to a left side-lying position with the right knee flexed. B. Prepare the client for a chest x-ray. C. Administer a cleansing enema. D. Auscultate the client’s bowel sounds.

Correct Answer is C

Explanation

Choice A rationale

Assisting the client to a left side-lying position with the right knee flexed is a common position for administering an enema. However, this action alone would not address the client’s immediate need for relief from constipation.

Choice B rationale

Preparing the client for a chest x-ray would not be the most appropriate action based on the client’s symptoms. The client is experiencing abdominal pain and constipation, which are not typically associated with conditions that would require a chest x-ray.

Choice C rationale

Administering a cleansing enema is the correct action. The client has not had a bowel movement for the past 7 days and reports abdominal pain. These symptoms, along with the findings from the abdominal x-ray, suggest that the client is experiencing constipation. A

cleansing enema can help to relieve constipation by stimulating bowel movements and removing impacted fecal matter.

Choice D rationale

Auscultating the client’s bowel sounds is an important part of assessing the client’s gastrointestinal status. However, given the client’s symptoms and the results of the abdominal x-ray, administering a cleansing enema would be the most appropriate action.

View Question and Answer

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

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

A nurse is attending to a patient who is experiencing discomfort. Which of the following patient statements should the nurse document in the initial pain assessment to describe the quality of the patient’s pain?

Correct Answer is A

Explanation

A client in the emergency department reports abdominal pain and has not had a bowel movement for the past 7 days. Based on the client’s clinical findings, which action should the nurse take?

Correct Answer is C

Explanation

A nurse is caring for a female client. The following diagnostic results have been recorded over two weeks: Exhibits Complete the following sentence by using the lists of options. The client is at risk for dropdown as evidenced by the dropdown.

A nurse is examining a patient’s medication prescription which states, “digoxin 0.25 by mouth daily.”. Which component of the prescription should the nurse confirm with the healthcare provider?

A nurse responds to a call light and finds a patient lying on the bathroom floor. What should the nurse do first?

A nurse in a medical-surgical unit is caring for six clients. The nurse needs to assess the clients based on their conditions. Exhibits Based on the Nurses’ Notes, which client should the nurse assess first? Please select the correct client number from the choices below:

A nurse is conducting a Romberg test as part of a patient’s physical assessment. Which of the following methods should the nurse employ?

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?

A nurse is administering fluids to a client.Which of the following assessments should the nurse identify as the priority when monitoring for adverse effects?

A nurse is providing dietary advice to a client at risk for hypokalemia. Which food should the nurse recommend for inclusion in the client’s diet?