In preparation for ambulation, the nurse plans to assist a postoperative client in transitioning from a lying to a sitting position. Which nursing action is most appropriate to maintain the client's safety?

Assess the client for signs of dizziness and hypotension

Assist the client to move quickly from the lying position to the sitting position

Elevate the head of the bed quickly to assist the client to a sitting position

Allow the client to rise from the bed to a standing position unassisted

Answer and Explanation

The Correct Answer is A

A. Assessing for dizziness and hypotension helps prevent falls and complications related to orthostatic changes during position changes.
B. Moving quickly increases the risk of dizziness and falls, which is unsafe.
C. Elevating the head of the bed quickly can cause sudden blood pressure drops and dizziness.
D. Allowing the client to stand unassisted postoperatively is unsafe due to potential weakness or hypotension.

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Correct Answer is D

Explanation

A. Routine use of antibiotic ointment on surrounding skin is not standard unless infection is present.
B. Occlusive dressings help maintain a moist wound environment but must be managed carefully; frequency depends on wound status.
C. Graduated compression stockings are recommended to improve venous return and aid ulcer healing; abstaining from them is not advised.
D. A high-calorie, high-protein diet supports tissue repair and immune function, promoting healing and preventing infection in clients with venous ulcers.

A. Retest the blood glucose level. B. Administer 15 g of carbohydrates C. Administer 1 mg of glucagon IM. D. Administer IV dextrose.

Correct Answer is B

Explanation

A. Retesting blood glucose can be done but should not delay treatment when hypoglycemia is confirmed at 60 mg/dL.
B. A glucose level of 60 mg/dL indicates mild hypoglycemia. The appropriate initial treatment is to administer 15 g of fast-acting carbohydrates (e.g., glucose tablets, juice) to quickly raise blood glucose.
C. Glucagon IM is reserved for severe hypoglycemia when the client is unconscious or unable to take oral carbohydrates.
D. IV dextrose is used in severe hypoglycemia or when oral intake is not possible; this client has mild symptoms and can likely swallow safely.

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In preparation for ambulation, the nurse plans to assist a postoperative client in transitioning from a lying to a sitting position. Which nursing action is most appropriate to maintain the client's safety?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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