A nurse is caring for a client who is experiencing acute delirium and has slipped down in their bed. Which of the following actions should the nurse take when repositioning the client?
Raise the rail on the side of the client's bed closest to the nurse.
Ask an assistive personnel to help move the client up in bed.
Ask the client to straighten their knees while pulling them up in bed.
Place the client in low-Fowler's position prior to moving them.
The Correct Answer is B
A. Raise the rail on the side of the client's bed closest to the nurse:
Raising the rail closest to the nurse may hinder access and compromise safety during repositioning. It's better to lower the rail on the working side.
B. Ask an assistive personnel to help move the client up in bed:
Clients with delirium need two-person assistance to safely reposition and prevent injury.
C. Ask the client to straighten their knees while pulling them up in bed:
A client with acute delirium may be confused or unable to follow instructions, making this unsafe.
D. Place the client in low-Fowler's position prior to moving them:
Low-Fowler’s may be used after repositioning, but does not assist in the actual movement up in bed.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Urinary incontinence
While common post-stroke, this is typically managed by physical therapy or medical providers, not speech pathologists.
B. Fine motor tremors
This is related to motor control and is best addressed by occupational or physical therapy.
C. Coughing while eating
This suggests possible dysphagia, a common post-stroke complication. A speech-language pathologist evaluates swallowing function to prevent aspiration.
D. Facial flushing
Not related to speech or swallowing. May be a nonspecific autonomic or emotional response.
Correct Answer is {"dropdown-group-1":"F","dropdown-group-2":"D"}
Explanation
The nurse should first address the client's pelvic ultrasound, followed by the client's quantitative beta-hCG.
Pelvic ultrasound is urgent to evaluate for possible ectopic pregnancy, especially given:
- Positive urine and abnormally low progesterone
- Discrepant and confusing hCG levels
- Right lower quadrant tenderness, spotting, and history of PID—all red flags for ectopic.
Quantitative beta-hCG interpretation becomes meaningful after imaging; it supports or confirms what the ultrasound suggests (e.g., nonviable pregnancy, ectopic gestation).
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.