After a week of bedrest, 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. Which action should the nurse implement next?

Offer a pair of non-skid socks.

Place the chair by the bed.

Support the client when rising.

Determine how the client feels.

Answer and Explanation

The Correct Answer is C

Choice A reason: Offering a pair of non-skid socks is not the most important action to implement next. The client may already have non-skid socks on, or may not need them if they are not walking. The priority is to prevent falls and injuries when transferring the client to the chair.

Choice B reason: Placing the chair by the bed is a necessary action to implement, but not the next one. The chair should already be by the bed before the nurse raises the head of the bed and moves the client to a sitting position. The next action is to help the client stand up and move to the chair.

Choice C reason: Supporting the client when rising is the best action to implement next. The client may be weak, dizzy, or unsteady after a week of bedrest, and may need assistance to stand up and sit down. The nurse should use proper body mechanics and a transfer belt if needed to support the client.

Choice D reason: Determining how the client feels is a relevant action to implement, but not the next one. The nurse should assess the client's vital signs, comfort, and tolerance of the activity after transferring the client to the chair. The next action is to ensure the client's safety and stability.

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Correct Answer is B

Explanation

Choice A reason: Placing a client in restraints without having a healthcare provider's order is not a tort, but a violation of the client's rights. The nurse should obtain an order for restraints as soon as possible and follow the facility's policy and procedure.

Choice B reason: Informing a client that the medication being administered is a vitamin is a tort, specifically a fraud. The nurse is deceiving the client and violating the principle of informed consent. The nurse should explain the purpose, benefits, and risks of the medication to the client and obtain the client's consent.

Choice C reason: Enlisting security personnel to assist with restraining the client is not a tort, but a prudent action. The nurse is ensuring the safety of the client and others by seeking help from trained staff. The nurse should document the incident and the rationale for the intervention.

Choice D reason: Administering the medication to a client behind a closed curtain is not a tort, but a respectful action. The nurse is maintaining the client's privacy and dignity by providing a quiet and secluded environment. The nurse should monitor the client's response and report any adverse effects.

A. Obtain the specimen from the client's current bowel movement. B. Contact the healthcare provider before obtaining the specimen. C. Withhold specimen collection until tarry black stool is observed. D. Wait to obtain the specimen until observable blood is present.

Correct Answer is A

Explanation

Choice A reason: This is the correct action because the nurse should obtain the specimen as soon as possible to avoid delays in diagnosis and treatment. The color and consistency of the stool do not affect the test for occult blood.

Choice B reason: This is not necessary because the nurse does not need to obtain a prescription or approval from the healthcare provider to collect a stool specimen for occult blood. The nurse should follow the standard protocol for specimen collection and labeling.

Choice C reason: This is incorrect because withholding specimen collection until tarry black stool is observed would delay the detection of occult blood. Tarry black stool indicates a bleeding source in the upper gastrointestinal tract, while occult blood can be present in any part of the gastrointestinal tract.

Choice D reason: This is also incorrect because waiting to obtain the specimen until observable blood is present would also delay the detection of occult blood. Observable blood indicates a bleeding source in the lower gastrointestinal tract, while occult blood can be present in any part of the gastrointestinal tract.

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After a week of bedrest, 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. Which action should the nurse implement next?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is preparing to give an emergency sedative injection to an agitated client. Which action by the nurse comprises a tort?

Correct Answer is B

Explanation

While preparing to obtain a stool specimen for occult blood, the nurse observes that the client's feces is soft, solid, and light brown. Which action should the nurse implement?

Correct Answer is A

Explanation

The practical nurse (PN) applies sterile gloves and opens a pack of sterile sponges to assist the healthcare provider with a bedside procedure. After the charge nurse observes the PN, which action should the charge nurse take?

After a week of bedrest, 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. Which action should the nurse implement next?

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The nurse observes an unlicensed assistive personnel (UAP) who is providing a total bed bath for a confused and lethargic client. The UAP is soaking the client's foot in a basin of warm water placed on the bed. Which action should the nurse take?

The healthcare provider prescribes a 24-hour urine specimen to be collected for creatinine clearance. The client is eager to go home and tells the nurse that the first sample was put in the urinal 2 hours ago. Which action should the nurse implement?

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