A nurse is administering a cold application to a client. Which of the following manifestations indicates the need to discontinue the application due to a systemic response by the client?

Reduced blood viscosity

Numbness

Hypotension

Shivering

Answer and Explanation

The Correct Answer is C

A. Reduced blood viscosity: This is a local effect of cold, not a harmful systemic response.
B. Numbness: Numbness can be an expected local response but is not necessarily systemic.
C. Hypotension: This indicates a systemic vasovagal response to cold and signals the need to stop the therapy.
D. Shivering: Shivering is a response to feeling cold but is less concerning than hypotension, which may compromise perfusion.

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Correct Answer is C

Explanation

A. The client's ability to communicate: Communication is important, but it is not the most critical factor in determining transfer method.
B. The client's activity tolerance: Activity tolerance affects length of mobility, but not necessarily the technique used for transfer.
C. The client’s current weight-bearing status: This determines whether the client needs full assistance, partial help, or assistive devices, and directly influences the transfer method and equipment used.
D. The type of equipment the staff used to transfer the client in the past: Past equipment may not match the client’s current condition.

A. Inserts one finger between the client's wrist and the restraint B. Ties the restraints to the side rails C. Places the padding of the restraints against the client's bony prominences D. Ties the straps of the restraints in a double knot

Correct Answer is C

Explanation

A. Inserts one finger between the client's wrist and the restraint: Best practice is to allow two fingers of space to ensure adequate circulation and comfort.
B. Ties the restraints to the side rails: Restraints must never be tied to movable parts (like side rails); they should be secured to the bed frame.
C. Places the padding of the restraints against the client's bony prominences: Padding helps prevent skin breakdown and pressure injuries over bony areas.
D. Ties the straps of the restraints in a double knot: Double knots are hard to remove in emergencies; a quick-release knot is recommended.

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A nurse is administering a cold application to a client. Which of the following manifestations indicates the need to discontinue the application due to a systemic response by the client?

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Naxlex Comprehensive Predictor Exams

A nurse is preparing to transfer a client from lying in bed to sitting in a chair. When identifying the safest method of transfer, which of the following assessment data is most important for the nurse to determine?

Correct Answer is C

Explanation

A charge nurse is reinforcing teaching for a newly licensed nurse about how to apply wrist restraints for a client. Which of the following actions should the charge nurse identify as an indication that the nurse understands the instructions?

Correct Answer is C

Explanation

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