The nurse enters the room of an older adult client and observes the client positioned in a wheelchair as seen in the picture. The unlicensed assistive personnel (UAP) is preparing to push the client's wheelchair in the hallway. Which instruction should the nurse provide the UAP before the client is moved into the hallway?

Use a belt restraint to secure the client in the chair.

Empty the client's urinary drainage bag.

Reposition the client's urinary drainage bag.

Elevate the client's feet higher on the foot rests.

Answer and Explanation

The Correct Answer is C

A.   Using a belt restraint is generally not recommended unless specifically ordered for safety reasons, as it may not be appropriate or necessary in all cases. Restraints should only be used when absolutely needed and when all other methods of ensuring safety have been considered.
B.   Emptying the urinary drainage bag before moving the client is important to prevent overflows and ensure that the bag does not become a source of discomfort or potential infection. However, this step might not always be immediately necessary unless the bag is full or the client’s comfort and hygiene are at risk.
C.   Repositioning the urinary drainage bag is crucial for ensuring that the bag remains below the level of the bladder and is not subject to kinks or obstructions. This helps prevent backflow and potential infections. Proper positioning also contributes to the client’s comfort and dignity, making this a priority before moving the client.
D.   Elevating the client’s feet on the footrests is important for their comfort and to prevent swelling or pressure sores, especially if the client has limited mobility or circulatory issues. Proper positioning can prevent discomfort and promote better circulation, which is essential for maintaining the client’s well- being during transport.

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Free Nursing Study Resources

Correct Answer is A

Explanation

A. This action is essential for effectively representing the client. Developing self-awareness of personal values ensures that the nurse does not impose their own beliefs on the client’s decisions. Instead, the nurse can advocate for the client's wishes based on the client's values and preferences, not their own.
B. While listening to the ethics committee is important, the nurse’s role as an advocate is to represent the client’s wishes and interests, not to dictate actions based on committee discussions. Informing the
client what actions should be taken may not be appropriate if it does not align with the client’s values or
preferences.
C. While it is important to advocate for the client's wishes, challenging team members should be done respectfully and constructively. The goal is not to create conflict but to ensure that the client’s preferences are considered.
D. Educating the client about nursing literature may be helpful, but it is not the primary responsibility of the nurse when serving as an advocate in an ethics committee meeting. The focus should be on
understanding and representing the client’s values and wishes rather than providing educational
information, unless it directly influences the client’s decision-making process.

A. Wear an emergency response pendant at home. B. Recommend installing grab bars by toilets, bathtub, and shower. C. Request that a family member move in with her. D. Encourage exercise to improve balance and mobility. E. Have the home health nurse assess the home for fall risks.

Correct Answer is ["A","B","D","E"]

Explanation

A. This device can be used to summon help quickly in case of a fall or other emergency.
B. Grab bars provide extra support and can help prevent falls in areas where the risk is high.
C. Request that a family member move in with her might be a solution for some people but it is not always practical or desirable. It's important to consider the client's preferences and independence when making recommendations.
D. Regular exercise can help strengthen muscles and improve balance, reducing the risk of falls.
E. A home health nurse can identify potential hazards in the home and make recommendations for modifications to improve safety.

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Naxlex Comprehensive Predictor Exams

The nurse has agreed to serve as a client's advocate at the meeting of the hospital ethics committee, which was called to address an ethical dilemma involving the client. To successfully represent the client, what action is essential for the nurse to take?

Correct Answer is A

Explanation

An older adult woman who lives alone talks with the clinic nurse about her fears of falling at home. Which interventions should the nurse suggest? Select all that apply.

Correct Answer is ["A","B","D","E"]

Explanation

In planning the turning schedule for a bedfast client, it is most important for the nurse to consider which assessment finding?

A client is admitted to the rehabilitation unit following a cerebrovascular accident (CVA), which resulted in paralysis of the right arm. When the nurse enters the room, the client is struggling to put on a shirt, and curses at the nurse. Which response is best for the nurse to provide?

A client who has a continuous tube feeding develops a fever and reports experiencing dyspnea. Which action should the nurse implement?

While changing the dressing of a client who is immobile, the nurse observes a red and swollen wound with a moderate amount of yellow and green drainage and a foul odor. Before reporting this finding to the healthcare provider, the nurse should note which of the client's laboratory values?

The nurse prepares to instill an adolescent client's ear drops as seen in the picture. Which should the nurse do next?

A surgical incision that is healing by secondary intention develops a thick tan exudate. Which action should the nurse take first?

The charge nurse is observing a new nurse administering care during new hire orientation at the hospital. Which activity by the new nurse indicates correct body movement and posture to reduce the risk for injury?