The practical nurse (PN) is preparing to transfer an older client from the bed to a wheelchair. Based on which finding should the PN request assistance when moving this client?

Presence of an indwelling catheter.

Stage two pressure ulcer on right buttock.

Low grade fever and warm, dry skin.

Impaired cognition and agitation.

Answer and Explanation

The Correct Answer is D

A. Presence of an indwelling catheter: An indwelling catheter does not typically require additional personnel for safe transfer. Standard precautions and careful positioning are usually sufficient.

B. Stage two pressure ulcer on right buttock: While care must be taken to avoid pressure on the ulcer, a stage two ulcer does not usually necessitate extra assistance for a safe transfer. Proper technique and padding can protect the site.

C. Low grade fever and warm, dry skin: Mild fever and skin warmth do not affect the client’s ability to participate in a transfer and do not require additional personnel.

D. Impaired cognition and agitation: Clients who are confused or agitated may be unpredictable and pose a safety risk during transfers. Requesting assistance ensures both client and nurse safety, allowing for controlled and safe movement to the wheelchair.

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Correct Answer is C

Explanation

A. Conjunctival redness: Redness of the eyes is a local effect of eye drops and does not significantly affect vision or balance, so it does not increase fall risk.

B. Elevated blood pressure: While systemic absorption of some glaucoma medications can affect blood pressure, this is less common and less directly linked to immediate fall risk than visual changes.

C. Pupillary constriction: Miotic eye drops used for glaucoma cause pupillary constriction, which can impair night vision and depth perception. This visual disturbance increases the risk of falls, making it important for staff to monitor clients closely.

D. Increased heart rate: Certain glaucoma medications may affect heart rate, but this is typically mild. Visual changes, rather than cardiovascular effects, pose the greatest immediate fall risk.

A. Place a heating pad on low setting to the area. B. Cleanse the skin to be treated with a mild soap. C. Apply nonperfumed moisturizing lotion to the site. D. After radiation, place ice bags over the treatment area.

Correct Answer is B

Explanation

A. Place a heating pad on low setting to the area: Applying heat to the radiation site can increase skin sensitivity and the risk of burns or irritation. Clients should avoid external heat sources during treatment.

B. Cleanse the skin to be treated with a mild soap: Gentle cleansing with mild soap helps maintain skin integrity without causing additional irritation. Proper hygiene minimizes infection risk and supports healthy skin during radiation therapy.

C. Apply nonperfumed moisturizing lotion to the site: Moisturizers may be used only if approved by the radiation team; some products can interfere with radiation delivery. Therefore, this instruction should not be given without specific provider guidance.

D. After radiation, place ice bags over the treatment area: Cold therapy is generally contraindicated immediately after radiation because it can further damage already sensitive skin. Clients should avoid applying ice directly to treated areas.

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The practical nurse (PN) is preparing to transfer an older client from the bed to a wheelchair. Based on which finding should the PN request assistance when moving this client?

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Naxlex Comprehensive Predictor Exams

Several residents of a long-term care facility are receiving eye drops to treat glaucoma. The practical nurse (PN) should caution the unlicensed assistive personnel (UAPS) caring for these clients to observe for which effect because it places the clients at risk for falls?

Correct Answer is C

Explanation

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Correct Answer is B

Explanation

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