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.

Answer and Explanation

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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Correct Answer is ["A","B","C"]

Explanation

A. Heart rate 99 beats/minute
A heart rate of 99 beats/minute is slightly elevated. Tachycardia can be a sign of fluid volume deficit, as the body compensates for decreased blood volume and pressure by increasing heart rate to maintain adequate perfusion.
B. Dark, yellow urine
Dark yellow urine indicates concentrated urine, which is a sign of dehydration or fluid volume deficit. Proper hydration would typically result in light yellow urine.
C. Urinated 30 mL
A urine output of 30 mL is low, especially for an adult in a 1-hour period. Low urine output can be a sign of fluid volume deficit, as the kidneys may not be excreting enough urine due to inadequate fluid intake or retention.
D. Temperature 101° F (38.3° C)
An elevated temperature indicates a fever, which is related to the infection (pneumonia) rather than fluid volume status. It does not directly indicate a fluid volume deficit.
E. Client is awake and alert
Being awake and alert indicates that the client’s neurological status is stable and is not indicative of fluid volume deficit. It does not reflect the client’s fluid volume status.
F. Blood pressure 115/71 mm Hg
A blood pressure of 115/71 mm Hg is within normal limits. While fluid volume deficits can affect blood pressure, this finding alone does not indicate a deficit since the blood pressure is stable.

A. Determine if the spouse has any medication allergies. B. Request the pharmacy to send acetaminophen to the unit. C. Give the spouse acetaminophen from the nurse's personal supply. D. Explain that medication can only be provided to clients.

Correct Answer is D

Explanation

A. Determining if the spouse has medication allergies is unnecessary because the PN should not provide medication to anyone other than the patient. Medication administration policies are strict about who can receive medications and ensuring compliance with these policies is crucial for legal and safety reasons.
B. The PN cannot request medication for individuals who are not patients under their care, so this action does not follow hospital procedures. Medications must be administered through proper channels to ensure they are given safely and legally.
C. Giving medication from the nurse’s personal supply is a violation of hospital policy and professional ethics. All medications must be obtained through approved sources and administered according to prescribed orders for safety and legal reasons.
D. Explaining that medication can only be provided to clients ensures adherence to hospital policies and legal regulations. This action maintains professional boundaries and ensures that only those who are officially under care receive medication.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Exhibits Following the infusion of sodium chloride, the practical nurse (PN) does a focused assessment and documents the findings. Which three of the following client findings indicate that the client may still have a fluid volume deficit?

Correct Answer is ["A","B","C"]

Explanation

The spouse of a hospitalized client asks the practical nurse (PN) for acetaminophen for a tension headache. Which action should the PN take?

Correct Answer is D

Explanation

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