A nurse is providing information to a client immediately before his scheduled Romberg test.

Which of the following statements should the nurse make?

"You will be standing with your feet 1 foot apart."

"You will place and hold your hands on your hips."

"I will be standing across the room from you to evaluate your sense of balance."

"I will be checking you once with your eyes open and once with them closed."

Answer and Explanation

The Correct Answer is D

A is incorrect because the client should stand with their feet together, not 1 foot apart, for the Romberg test.

B is incorrect because the client should hold their arms at their sides, not on their hips, for the Romberg test.

C is incorrect because the nurse should stand close to the client, not across the room, to prevent injury in case of a fall.

D is correct because the Romberg test involves checking the client's balance with their eyes open and then with their eyes closed.

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Correct Answer is A

Explanation

A. Correct. A hemoglobin level of 14.9 g/dL indicates that the client has an adequate amount of oxygen-carrying capacity in the blood, which is the goal of blood transfusion therapy.
B. Incorrect. A WBC count of 12,000/mm3 is slightly elevated and may indicate an infection or inflammation, which are not related to blood transfusion therapy.
C. Incorrect. A potassium level of 48 mEq/L is dangerously high and may cause cardiac arrhythmias, muscle weakness, or paralysis. This is not an expected outcome of blood transfusion therapy and may indicate hemolysis or renal impairment.
D. Incorrect. A BUN level of 18 mg/dL is within the normal range and does not reflect the effectiveness of blood transfusion therapy.

A. The last time the provider evaluated the client B. The client's most recent ventilator settings C. The time of the client's last dose of pain medication D. The frequency in which the client presses the call button E. None F. None

Correct Answer is C

Explanation

a. The last time the provider evaluated the client:This information helps the receiving nurse stay updated on the client's clinical status and recent provider recommendations.
b. The client's most recent ventilator settings:The client's most recent ventilator settings (B) would no longer be relevant if the client has been successfully weaned off mechanical ventilation.
c. The time of the client's last dose of pain medication:This helps manage the client's pain effectively and prevent potential withdrawal symptoms.

d. This information is not clinically relevant for the next nurse’s shift. While the frequency of call button use may reflect a client's needs or comfort level, it is not a priority for safe, evidence-based clinical care and does not impact the client’s medical treatment or condition.

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A nurse is providing information to a client immediately before his scheduled Romberg test. Which of the following statements should the nurse make?

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A nurse is providing information to a client immediately before his scheduled Romberg test.

Which of the following statements should the nurse make?