A male client has right-sided hemiplegia following a left cerebrovascular accident (CVA). His sitting balance has improved, and he is now able to sit in a wheelchair. To assist the client in transferring from the bed to a wheelchair, which action should the nurse take?

Place the wheelchair on the client's left side.

Instruct the client to take slow, deep breaths while transferring.

Instruct the client to look at his feet.

Have the client put both arms around the nurse's neck for support.

Answer and Explanation

The Correct Answer is A

A. Place the wheelchair on the client's left side is the most appropriate action. Since the client has right-sided hemiplegia, the nurse should place the wheelchair on the client's left side to allow for easier transfer. The left side is the stronger side, and the client will be able to use this side to assist with the transfer.

B. Instruct the client to take slow, deep breaths while transferring may help with relaxation, but it is not the priority in this scenario. The focus should be on positioning and safety during the transfer.

C. Instruct the client to look at his feet is not advisable because it may disrupt the client's balance or lead to a fall. The client should focus on using the stronger side to assist with the transfer.

D. Have the client put both arms around the nurse's neck for support is not safe and could cause strain or injury to both the client and the nurse. The client should be instructed to use proper body mechanics and rely on the nurse for support during the transfer, but not in a way that could lead to injury.

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Correct Answer is B

Explanation

A. Capillary refill time is 2 seconds is within the normal range and is unlikely to interfere with the pulse oximeter reading.

B. 2+ edema of fingers and hands most likely contributes to the low oxygen saturation reading. Edema can impair the accuracy of a pulse oximeter by affecting the transmission of light through the tissues, leading to erroneous readings.

C. Blood pressure is 142/88 mm Hg is mildly elevated but does not directly affect the pulse oximeter's ability to measure oxygen saturation.

D. Radial pulse volume is 3+ indicates a strong pulse and does not interfere with the functionality of the pulse oximeter.

A. Adjust the flow rate to the prescribed liters per minute. B. Assess the position of the mask on the client's face. C. Attach the flowmeter to a humidification canister. D. Release and reinsert the flowmeter in the wall outlet.

Correct Answer is D

Explanation

A. Adjust the flow rate to the prescribed liters per minute is not the first action to take. The loud hissing sound indicates a potential issue with the connection of the flowmeter, so the nurse should first address that before adjusting the flow rate.

B. Assess the position of the mask on the client's face is important, but the loud hissing sound suggests a problem with the oxygen delivery system rather than with the mask itself. The nurse should check the flowmeter connection first.

C. Attach the flowmeter to a humidification canister is unnecessary unless the prescription specifically includes humidification. The priority is to ensure the flowmeter is properly inserted into the wall outlet and the oxygen system is functioning correctly.

D. Release and reinsert the flowmeter in the wall outlet is the correct action. The loud hissing sound may be caused by an improper or loose connection between the flowmeter and the wall outlet. The nurse should ensure the flowmeter is securely attached to prevent leakage and ensure proper oxygen delivery.

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A male client has right-sided hemiplegia following a left cerebrovascular accident (CVA). His sitting balance has improved, and he is now able to sit in a wheelchair. To assist the client in transferring from the bed to a wheelchair, which action should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse attaches a pulse oximeter to a client's finger and obtains an oxygen saturation reading of 91%. Which assessment finding most likely contributes to this reading?

Correct Answer is B

Explanation

When initiating oxygen per mask to a client who is short of breath, the nurse hears a loud hissing sound after inserting the flowmeter into the wall outlet. Which should the nurse do next?

Correct Answer is D

Explanation

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