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 A

Explanation

A. Perform oral hygiene at least every 2 hours:

Regular oral care is essential to maintain oral health, prevent infections, and provide comfort. When a client is NPO, and especially if they are weak or drowsy, the nurse should perform oral care at least every 2 hours to keep the oral cavity moist, reduce the risk of infection, and provide comfort.

B. Client must be supine with the head of the bed below 30 degrees:

Keeping the head of the bed elevated to at least 30 degrees is important for preventing aspiration and promoting respiratory function. This position is not specific to oral care but is a general guideline for managing clients at risk for aspiration.

C. Use alcohol-based mouth rinse with oral swab:

Alcohol-based mouth rinses can be drying and may not be suitable for a client who is NPO, as they might contribute to further dryness of the oral mucosa. Non-alcohol-based mouth rinses or moistened oral swabs are often preferred.

D. Assist the client with oral care by brushing their teeth twice daily:

While regular oral care is important, the frequency of twice daily brushing may not be sufficient for a weak, drowsy client, especially if they are NPO. Oral care should be performed more frequently to maintain oral hygiene.

A. Allow the patient to relax and then recheck the patient’s B/P in 5 minutes. B. Document the elevated B/P and notify the physician immediately C. Begin education related to hypertension (high B/P) D. Schedule the patient for follow-up visits for measurement and monitoring of patient’s blood pressure

Correct Answer is A

Explanation

A. Allow the patient to relax and then recheck the patient’s B/P in 5 minutes:

The initial elevated blood pressure reading could be influenced by the patient's anxiety about visiting the doctor. Allowing the patient to relax and rechecking the blood pressure after a few minutes may provide a more accurate reading.

B. Document the elevated blood pressure and notify the physician immediately:

It is premature to immediately notify the physician based on a single elevated blood pressure reading. Reassessing after the patient has had time to relax is a reasonable approach before taking further action.

C. Begin education related to hypertension (high blood pressure):

While patient education is important, addressing the patient's anxiety and obtaining accurate blood pressure readings should be the initial focus.

D. Schedule the patient for follow-up visits for measurement and monitoring of the patient’s blood pressure:

Scheduling follow-up visits may be necessary based on subsequent assessments, but the immediate concern is to recheck the blood pressure after allowing the patient to relax.

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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

The nurse is providing oral care for a client who is weak, drowsy, and unable to take anything by mouth (NPO). Which of the following would the nurse implement when performing appropriate oral care for this client?

Correct Answer is A

Explanation

Correct Answer is A

Explanation

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