The nurse is caring for a client who has been on bed rest. The primary care provider has just written a new order for the client to sit in the chair three times a day. Which of the following is the best action to transfer the client, for the first time, safely into the chair?

Infuse an intravenous fluid bolus 15 minutes before transferring the client into the chair.

Obtain a quad cane for the client to use as a transfer aid.

Position a friction-reducing sheet under the client.

Have the client sit on the side of the bed for several minutes before moving to the chair.

Answer and Explanation

The Correct Answer is D

A. Infusing an intravenous fluid bolus 15 minutes before transferring the client into the chair:

Administering an IV fluid bolus before transferring the client to a chair is not necessary and not directly related to the safe transfer from bed to chair. It doesn't directly assist with the physical transfer process.

B. Obtaining a quad cane for the client to use as a transfer aid:

While a quad cane can be helpful for some individuals with mobility issues, it might not be necessary for the initial transfer from bed to chair and may not be appropriate for everyone.

C. Positioning a friction-reducing sheet under the client:

While a friction-reducing sheet can assist with moving a client, it may not be necessary for the initial transfer from bed to chair, especially if the client can bear weight and perform the transfer safely.

D. Having the client sit on the side of the bed for several minutes before moving to the chair:

This is the best action. Allowing the client to sit on the side of the bed for a few minutes helps the body adjust to being in a sitting position after an extended period of lying down. It allows for gradual adaptation and reduces the risk of dizziness or orthostatic hypotension when moving from lying down to sitting up.

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Correct Answer is C

Explanation

A. Do not let the patient know you are counting their respirations:

This is not directly related to obtaining vital signs and is not a critical factor for a patient with a low platelet count.

B. Let the patient rest for 5 minutes before you measure their blood pressure:

Allowing the patient to rest for a few minutes before measuring blood pressure is a good practice but may not be as critical as other considerations in a patient with a low platelet count.

C. Do not measure the patient’s temperature rectally:

Patients with low platelet counts are at an increased risk of bleeding. Rectal temperatures can be invasive and carry a risk of mucosal injury, making them less advisable in patients with bleeding risks.

D. Count the patient’s radial pulse for 30 seconds and multiply it by 2:

Counting the radial pulse is a suitable method for assessing heart rate in a patient at risk for bleeding. However, rectal temperature measurement should be avoided due to the risk of mucosal injury.

A. 74 year old female with malnutrition and a foley catheter in place B. 54 year old female admitted for chest pain observation C. 34 year old male admitted for seizure observation D. 78 year old male with right sided hemiplegia following a stroke

Correct Answer is A

Explanation

A. 74-year-old female with malnutrition and a foley catheter in place:

Malnutrition can weaken the immune system, making the individual more susceptible to infections. Additionally, the presence of a foley catheter increases the risk of urinary tract infections.

B. 54-year-old female admitted for chest pain observation:

Chest pain observation does not inherently increase the risk of infection.

C. 34-year-old male admitted for seizure observation:

Seizure observation does not inherently increase the risk of infection.

D. 78-year-old male with right-sided hemiplegia following a stroke:

While the hemiplegia following a stroke may pose mobility challenges, the presence of malnutrition and a foley catheter in option A puts the patient at a higher risk for infection.

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The nurse is caring for a client who has been on bed rest. The primary care provider has just written a new order for the client to sit in the chair three times a day. Which of the following is the best action to transfer the client, for the first time, safely into the chair?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a patient who has a low platelet count and is at risk for bleeding. Which of the following is a critical factor or priority that the nurse should apply when considering how to obtain the patient’s vital signs?

Correct Answer is C

Explanation

The nurse would recognize which of the following patients would be at highest risk for developing an infection?

Correct Answer is A

Explanation

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