When assisting a client from the bed into a wheelchair, the nurse assesses the client on standing and notices the client is weak and unsteady. What would be the recommended nursing intervention in this situation?

Return the client to the bed.

Use the call bell to summon the assistance of another nurse.

Place the client into the wheelchair.

Allow the client to keep standing for several minutes until balance returns.

Answer and Explanation

The Correct Answer is A

A. Returning the client to the bed is the safest action when the client appears weak and unsteady upon standing. This helps prevent a potential fall or injury. Once the client is safely back in bed, the nurse can reassess and consider other options for mobility support.
B. Using the call bell may take time and does not ensure the client’s immediate safety, which is the priority in this moment.
C. Placing the client into the wheelchair while they are unsteady poses a high risk for falls or injury.
D. Allowing the client to continue standing may worsen the situation if they are already weak, increasing the risk of collapse or injury.

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Correct Answer is C

Explanation

A. 0930 in military time is 9:30 a.m., not p.m.
B. 930 p.m. is not military time format; military time uses a 24-hour clock without a.m./p.m. designations.
C. 2130 in military time represents 9:30 p.m. (21:30 hours).
D. 1930 represents 7:30 p.m., not 9:30 p.m.

A. Reassure the family that this is a common problem. B. Apply a pressure dressing and report findings. C. Document the data and apply a new dressing. D. Make assessments every 15 minutes for 4 hours.

Correct Answer is B

Explanation

A. Reassuring the family without addressing the issue is unsafe.
B. Applying a pressure dressing helps control bleeding, and reporting findings promptly ensures timely medical intervention.
C. Simply documenting and changing the dressing without addressing bleeding risks worsening the condition.
D. Waiting to monitor without immediate intervention could allow the client’s condition to deteriorate.

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When assisting a client from the bed into a wheelchair, the nurse assesses the client on standing and notices the client is weak and unsteady. What would be the recommended nursing intervention in this situation?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is documenting an assessment that was completed at 9:30 p.m. The facility uses military time for documentation. What entry should the nurse make for the time care was given?

Correct Answer is C

Explanation

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Correct Answer is B

Explanation

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