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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. A living will is a legal document that lists specific instructions about the type of health care a person wants or does not want if they become unable to make decisions.
B. It does not determine an individual's quality of life; rather, it reflects their wishes regarding medical treatment.
C. A living will does not address inheritance or estate matters.
D. Identifying a trusted person to make health care decisions is done through a durable power of attorney for health care, not a living will.
Correct Answer is D
Explanation
A. Nurses provide support but do not usually decide disclosure.
B. Clergy may offer spiritual support but do not decide medical disclosure.
C. Family members may want to be involved but don’t have the primary responsibility.
D. The health care provider is typically responsible for deciding what, when, and how to disclose the diagnosis to the client.
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