A nurse is assisting with transferring a client from the bed to a wheelchair. Which of the following actions should the nurse take?

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

Acquire the help of several people to lift the client.

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

Lock the wheels of the bed and the wheelchair.

Answer and Explanation

The Correct Answer is D

A.   Elevating the bed for the comfort of the nurse does not address the safety and comfort of the client during the transfer.
B.   While it's important to have assistance if needed, using several people to lift the client may not always be necessary or appropriate.
C.   This positioningis not optimal, as it makes it harder for the client to pivot and sit on the wheelchair.
D.   Ensuring the wheels of both the bed and the wheelchair are locked helps maintain stability and safety during the transfer process, reducing the risk of accidental movement and potential falls.

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Correct Answer is ["B","C","E"]

Explanation

A. Increased fiber in the diet is not a cause of constipation, but rather a preventive measure that can help promote regular bowel movements by adding bulk and softness to the stool.
B. Ignoring the urge to defecate is a cause of constipation, as it can lead to hardening and accumulation of fecal matter in the colon, resulting in difficulty and pain during defecation.
C. Inadequate fluid intake is a cause of constipation, as it can contribute to dehydration and reduced stool moisture, making it harder and drier to pass.
D. Increased activity is not a cause of constipation, but rather a beneficial factor that can stimulate intestinal motility and facilitate bowel elimination.
E. Excessive laxative use is a cause of constipation, as it can interfere with the normal functioning of the colon and cause dependence, leading to decreased bowel tone and reduced peristalsis.

A. Observe the client's respiratory status. B. Monitor intake and output every 8 hr. C. Elevate the head of the client's bed 30° to 45°. D. Check residual volume every 4 to 6 hr.

Correct Answer is C

Explanation

A. Observing the client's respiratory status is also important, but it is an ongoing assessment rather than an immediate action.

B. Monitoring intake and output every 8 hours is important for overall fluid balance, but it is not the top priority in this situation.

C. This is crucial to prevent aspiration, which can occur if the feeding formula enters the lungs, leading to pneumonia or other serious complications. Elevating the head of the bed helps keep the esophagus above the stomach, reducing the risk of aspiration.

D. Checking residual volume every 4 to 6 hours is a part of enteral feeding care, but it is not the top priority. Monitoring respiratory status takes precedence due to the potential risk of aspiration.

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A nurse is assisting with transferring a client from the bed to a wheelchair. Which of the following actions should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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