After a week of bed rest, a client is being assisted to a chair for the first time.
The nurse raises the head of the bed and moves the client to a sitting position. What should the nurse implement next?
Determine how the client feels.
Support the client when rising.
Offer a pair of non-skid socks.
Place the chair by the bed.
The Correct Answer is A
After moving the client to a sitting position, the next step the nurse should implement is to determine how the client feels.
This allows the nurse to assess for any dizziness, lightheadedness, or other symptoms that may indicate orthostatic hypotension or other issues.
Choice B, supporting the client when rising, is important but should be done after assessing how the client feels.
Choice C, offering a pair of non-skid socks, may be helpful for safety but is not the most important action in this situation.
Choice D, placing the chair by the bed, should be done before moving the client to a sitting position.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
The most important intervention the nurse should take when administering these medications to the client is to assess the client’s pain level and administer the appropriate medication based on the level of pain.
Choice A is not the correct answer because administering all medications at the same time may not provide effective pain relief and could result in overmedication.
Choice B is not the correct answer because administering the medication with the highest dose first may not provide effective pain relief and could result in overmedication.
Choice D is not the correct answer because administering the medication with the longest duration of action first may not provide immediate pain relief.
Correct Answer is C
Explanation
When checking the restraints, the most important action for the nurse to take is to assess capillary refill distal to the restraints.
This helps to ensure that the restraints are not too tight and that blood flow to the extremities is not compromised.
Choice B, verifying that the restraints can be quickly released, is important for safety but does not directly address the client’s physical well-being.
Choice D, replacing the nasogastric tube, may also be necessary but is not the most important action in this situation.
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