A nurse is assisting a client who has generalized weakness to move from the bed to a wheelchair. What actions should the nurse take?

Lock the wheels of the bed and the wheelchair.

Elevate the bed to a position of comfort for the nurse.

Get the help of several staff members to lift the client.

Place the wheelchair at a 90° angle to the bed.

Answer and Explanation

The Correct Answer is B

Choice A rationale
Locking the wheels of the bed and the wheelchair is an important safety measure when assisting a client to move from the bed to a wheelchair. However, this action alone is not sufficient. The nurse also needs to ensure the client’s safety during the transfer by using proper body mechanics and providing adequate support.
Choice B rationale
Elevating the bed to a position of comfort for the nurse is the correct action. This helps to ensure that the nurse can maintain proper body mechanics during the transfer, reducing the risk of injury to both the nurse and the client.
Choice C rationale
Getting the help of several staff members to lift the client is not typically necessary when transferring a client with generalized weakness from the bed to a wheelchair. With proper positioning and technique, one nurse can often safely assist the client with this type of transfer.
Choice D rationale
Placing the wheelchair at a 90° angle to the bed is not the recommended position when transferring a client from the bed to a wheelchair. Instead, the wheelchair should be positioned parallel to the bed or at a slight angle.

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Correct Answer is A

Explanation

Choice A rationale

The client should lift the walker and place it down in front of her. This is because lifting the walker provides stability and support as the client moves. It’s important for the client to move the walker first, then step forward to ensure balance and prevent falls.
Choice B rationale
Walking in front of the client to guide her in moving the walker is not the best practice. The client should be allowed to set the pace and the nurse should be beside or slightly behind the client to provide assistance if needed.
Choice C rationale
Having the client move one leg forward with the walker is not the most effective way to use a walker. Both legs should move forward after the walker has been placed down in front of the client.
Choice D rationale
Making sure that the upper bar of the walker is level with the client’s waist is a good practice, but it’s not the best answer for this question. The height of the walker should be adjusted so that the handles are at the level of the client’s wrists when the client’s arms are hanging down. This allows the client to maintain a slight bend in their elbows when holding the handles.

A. Request a prescription for the insertion of an indwelling urinary catheter. B. Apply a moisture barrier ointment to the skin. C. Clean the skin and perineum with hot water after each episode of incontinence. D. Check the client’s skin every 8 hours for signs of breakdown. E. Check the client’s skin every 8 hours for signs of breakdown.

Correct Answer is B

Explanation

Choice A rationale
Requesting a prescription for the insertion of an indwelling urinary catheter is not the best option to prevent skin breakdown in a client with urinary incontinence. Catheters can increase the risk of urinary tract infections and should be used as a last resort.
Choice B rationale

Applying a moisture barrier ointment to the skin can help protect the skin from the damaging effects of urine. This can help prevent skin breakdown and is a common practice in the care of clients with urinary incontinence.
Choice C rationale
Cleaning the skin and perineum with hot water after each episode of incontinence is not recommended. Hot water can dry out the skin and cause irritation. It’s better to use warm water and a gentle cleanser.
Choice D rationale
Checking the client’s skin every 8 hours for signs of breakdown is important, but it’s not the only action the nurse should take. The nurse should also take proactive measures to protect the skin, such as applying a moisture barrier ointment.

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A nurse is assisting a client who has generalized weakness to move from the bed to a wheelchair. What actions should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assisting an older adult client in the hallway for the first time since admission. The client has brought a standard walker from home.To ensure the client’s safety and proper use of the walker, which of the following actions should the nurse take?

Correct Answer is A

Explanation

A nurse is caring for a client with urinary incontinence. What action should the nurse take to prevent skin breakdown?

Correct Answer is B

Explanation

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