The nurse is assisting to lift a client from a wheelchair after surgery. To ensure safe mobility, which action should the nurse take?

Bend at the knees to maintain a low center of gravity.

Ask the client to place hands on the nurse's shoulders.

Stand with feet 3 inches (7.6 cm) apart for balance.

Position self at the back of wheelchair with wheels locked.

Answer and Explanation

The Correct Answer is A

A. Bend at the knees to maintain a low center of gravity: Bending at the knees allows the nurse to use the strong muscles of the legs instead of the back, promoting proper body mechanics and reducing the risk of injury during lifting.

B. Ask the client to place hands on the nurse's shoulders: This is unsafe, as it may cause the client to pull the nurse off balance. Clients should be instructed to push off stable surfaces, such as the armrests of the wheelchair.

C. Stand with feet 3 inches (7.6 cm) apart for balance: A 3-inch stance does not provide adequate support. Feet should be about shoulder-width apart (usually 12–18 inches) to maintain a stable base during lifting or transferring.

D. Position self at the back of wheelchair with wheels locked: While locking the wheels is correct, standing behind the wheelchair does not assist the client in rising. The nurse should be in front or to the side to offer support during the transfer.

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Correct Answer is B

Explanation

A. Assess strength of deep tendon reflexes: Hypokalemia can reduce reflex responses, but this is not the most urgent concern. Neuromuscular changes are secondary to the more dangerous cardiac effects of low potassium.

B. Determine apical heart rate and rhythm: A potassium level of 2.5 mEq/L is critically low and places the client at high risk for life-threatening cardiac dysrhythmias. Monitoring heart rate and rhythm is the top priority for early detection of complications like arrhythmias or cardiac arrest.

C. Compare muscle strength bilaterally: Hypokalemia can cause muscle weakness, but cardiac monitoring is a higher priority due to the potential for immediate, severe complications.

D. Observe color and amount of urine: While relevant for overall fluid and renal status, this does not directly assess the most life-threatening effects of hypokalemia.

A. Offer assurance that this particular immunization is less painful than imagined. B. Use distraction to redirect the client's attention while the nurse gives the injection. C. Review the importance of receiving the immunization as a protection from disease. D. Invite the client to use the syringe on a dummy before receiving the immunization.

Correct Answer is B

Explanation

A. Offer assurance that this particular immunization is less painful than imagined: Minimizing the client’s fear may come across as dismissive and does not address the adolescent’s expressed concern about pain, which may increase anxiety rather than reduce it.

B. Use distraction to redirect the client's attention while the nurse gives the injection: Distraction techniques are effective in reducing perceived pain and anxiety during injections. Shifting the client’s focus away from the procedure helps manage the emotional response and improves the overall experience.

C. Review the importance of receiving the immunization as a protection from disease: Providing education is important, but focusing solely on the rationale does not address the immediate emotional distress related to fear of pain. It may seem unempathetic in the moment.

D. Invite the client to use the syringe on a dummy before receiving the immunization: This action might heighten the adolescent's anxiety by drawing more attention to the needle and procedure. It is not a standard or effective strategy for managing fear of injections.

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The nurse is assisting to lift a client from a wheelchair after surgery. To ensure safe mobility, which action should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

When assessing a client with a serum potassium level of 2.5 mEq/L (2.5 mmol/L), which intervention is most important for the nurse to implement?Reference Range Potassium (K+)[3.5 to 5,0 mEq/L (3.5 to 5.0 mmol/L)]

Correct Answer is B

Explanation

An adolescent is scheduled to receive a required immunization injection. The client reports being afraid of injections because "shots hurt.” Which action should the nurse take?

Correct Answer is B

Explanation

A client arrives to the clinic describing concerns to the nurse about mood swings, insomnia, and a lack of focus. Which information should the nurse obtain first?

The nurse is providing end-of-life care and determines the client is experiencing anxiety about the future. Which portion of the nursing process should the nurse use to guide the plan of care?

When administering 0900 medications to four clients, which prescription should the nurse administer first?

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?

A client's spouse has just learned of the client's terminal illness. The spouse is sitting in the corner of the client's room crying, and says to the nurse. "I feel as if I'm already so alone." 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?

When initiating oxygen per mask to a client who is short of breath, the nurse hears a loud hissing sound after inserting the flowmeter into the wall outlet. Which should the nurse do next?

The nurse assesses a client who has a nasal cannula delivering oxygen at 2 liters/minute. To assess for skin damage related to the cannula, which areas should the nurse observe? Select all that apply.