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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason: Positive external places are images of pleasant and relaxing environments that can distract the client from the pain and induce a sense of calmness and well-being. Examples of positive external places are a beach, a garden, or a mountain.
Choice B reason: Emotional reflection is a process of exploring and expressing one's feelings and emotions. It may be helpful for some clients to cope with stress and anxiety, but it is not the best focus for guided imagery for chronic pain. Emotional reflection may trigger negative emotions or memories that can worsen the pain perception.
Choice C reason: Motivational phrases are statements that encourage and inspire the client to achieve a goal or overcome a challenge. They may be useful for some clients to boost their self-confidence and self-efficacy, but they are not the best focus for guided imagery for chronic pain. Motivational phrases may not be effective in reducing the pain intensity or duration.
Choice D reason: Tranquil sounds are noises that create a soothing and peaceful atmosphere. They may be helpful for some clients to relax and fall asleep, but they are not the best focus for guided imagery for chronic pain. Tranquil sounds may not be enough to divert the client's attention from the pain or create a positive emotional state.
Correct Answer is D
Explanation
Choice A reason: Giving positive feedback to the PN and documenting the skill competency is not the appropriate action to take. The PN did not demonstrate proper sterile technique, as he touched the outside of the sterile glove package and the sterile sponges with his bare hands, contaminating them.
Choice B reason: Explaining to the PN that the sterile sponges are not needed for the procedure is not the relevant action to take. The PN may have been following the instructions of the healthcare provider, who may have requested the sponges for the procedure. The issue is not the need for the sponges, but the way the PN handled them.
Choice C reason: Reminding the PN to wash his hands before applying the sterile gloves is not the sufficient action to take. Washing the hands is an important step in maintaining infection control, but it does not correct the mistake the PN made by touching the sterile items with his bare hands.
Choice D reason: Asking the PN to remove the gloves and sponges and start over with a new set is the best action to take. It ensures that the PN follows the correct sterile technique and does not compromise the safety of the client or the procedure. It also provides an opportunity for the charge nurse to teach the PN how to avoid contamination.
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