The practical nurse (PN) is preparing to transfer an unresponsive client from the bed to a stretcher. Which client data is most important for the PN to obtain before beginning the transfer?
Skin turgor.
Body weight.
Temperature.
Blood pressure.
The Correct Answer is D
A. Skin turgor is important for assessing hydration status, but it is not the most critical factor when preparing for a safe transfer. For an unresponsive client, ensuring stable hemodynamic conditions is more urgent. Blood pressure provides essential information about the client’s circulatory status, which is crucial for assessing the risks associated with the transfer.
B. Body weight is generally used for dosing medications or assessing nutritional status and is not immediately relevant for ensuring a safe transfer of an unresponsive client. Although body weight might be useful in planning the transfer logistics, it does not impact immediate safety concerns.
C. Temperature can indicate infection or other issues but does not directly affect the immediate safety of the transfer process. While monitoring temperature is part of overall care, it is not the most pressing concern during the transfer.
D. Blood pressure is essential to check before the transfer because it reflects the client’s cardiovascular stability. Low or unstable blood pressure might increase the risk of complications during the transfer, such as a sudden drop in blood pressure that could lead to a fall or injury.
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Related Questions
Correct Answer is B
Explanation
A. Encouraging the client to proceed with the surgery may dismiss their valid fears and does not address the underlying emotional concerns. It is important to acknowledge the client’s feelings rather than pressuring them to continue.
B. Notifying the charge nurse of the client’s concerns ensures that the client’s emotional state and any potential issues with informed consent are addressed appropriately. The charge nurse can facilitate further discussion with the surgical team to ensure the client’s concerns are managed and that the consent remains valid.
C. Documenting the client’s concerns is important for legal and clinical reasons, but it does not address the client’s immediate emotional needs or resolve their fears. The priority is to ensure the client’s concerns are addressed and escalated if necessary.
D. Reminding the client that consent has already been obtained does not validate their current emotional concerns and can be dismissive. The focus should be on addressing the client’s anxiety and exploring their concerns.
Correct Answer is C
Explanation
A. Irrigating the infected area with a medicated solution is not appropriate for nystatin suspension, which should be applied directly to the infected area. Additionally, sterile gloves are not required for this procedure.
B. Drawing up the medication in a needle-less syringe for the infant to suck is not an effective method for nystatin administration. The medication must be applied directly to the infected area to be effective.
C. Using a gloved finger to rub the suspension over the infected area is the correct method for applying nystatin. This direct application ensures that the medication comes into contact with the infection and is most effective for treating oral candida.
D. Measuring the medication into the infant’s bottle does not ensure that the nystatin is applied to the infected area and may result in the medication being swallowed rather than effectively treating the candida infection.
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