A nurse is caring for a client who is sitting in a chair and asks to return to bed.
Which of the following actions is the nurse's priority?

Obtain a walker for the client to use to transfer back to bed.

Call for additional staff to assist with the transfer.

Use a transfer belt and assist the client back into bed.

Determine the client's ability to help with the transfer.

Answer and Explanation

The Correct Answer is D

The correct answer is D. Determine the client's ability to help with the transfer.

Choice A rationale:

While obtaining a walker might be helpful, it's not the first step. The nurse needs to assess the client's ability to assist with the transfer before deciding on the most appropriate aid.

Choice B rationale:

Calling for additional staff may be necessary, but this should come after assessing the client's ability to help with the transfer.

Choice C rationale:

Using a transfer belt is a good practice for safe transfers, but again, the nurse must first determine if the client can assist. This ensures the appropriate use of resources and techniques.

Choice D rationale:

Assessing the client's ability to help with the transfer is the first step. This assessment will guide the nurse in choosing the safest and most appropriate method for transferring the client, considering their capabilities and safety.

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Correct Answer is C

Explanation

Choice A rationale:

This option is incorrect. Tachypnea refers to abnormally fast breathing, typically defined as a respiratory rate higher than 20 breaths per minute in adults. It is the opposite of the condition described in the question, where the respiratory rate has fallen below 10 respirations per minute.

Choice B rationale:

This option is incorrect. Apnea refers to the absence of breathing, often resulting from a temporary cessation of airflow to the lungs. It is characterized by the complete absence of respiratory movements and sounds, which is different from the situation described in the question where the client is breathing at a very slow rate.

Choice C rationale:

Bradypnea, or abnormally slow breathing, is the correct answer in this case. It is defined as a respiratory rate lower than the normal range, which is typically between 12 to 20 breaths per minute in adults. Bradypnea can be caused by various factors, including drug overdose, neurological disorders, or metabolic imbalances. In this scenario, the client's slow respiratory rate (below 10 respirations per minute) indicates bradypnea.

Choice D rationale:

This option is incorrect. Eupnea refers to normal breathing, where the rate and depth of respirations are within the normal range. It does not describe the condition of the sedated client in the question, who is experiencing abnormally slow breathing (bradypnea)

A. Fall history. B. Medical diagnosis. C. Use of assistive devices. D. Mental status. E. Do-not-resuscitate status.

Correct Answer is ["A"]

Explanation

Choice A rationale:

Maintaining the patency of the client's airway is the priority action. During a seizure, the client may lose consciousness and have difficulty breathing. Ensuring a clear airway is essential to prevent hypoxia and maintain oxygenation. This can be achieved by positioning the client on her side and removing any obstructions from her mouth to allow for adequate airflow.

Choice B rationale:

Identifying the poison the client ingested is important for providing appropriate medical treatment, but it is not the priority action in this scenario. Airway management takes precedence because it addresses the immediate threat to the client's life.

Choice C rationale:

Measuring the client's blood pressure is a necessary assessment, but it is not the priority during an active seizure. Airway management and seizure control are the immediate concerns. Once the seizure is controlled and the airway is secured, other assessments, including blood pressure measurement, can be performed.

Choice D rationale:

Positioning the client on her side is a correct action, but it should be done after ensuring the patency of the airway. Placing the client on her side helps prevent aspiration in case of vomiting during or after the seizure. However, it is not the priority over ensuring the client can breathe properly.

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A nurse is caring for a client who is sitting in a chair and asks to return to bed. Which of the following actions is the nurse's priority?

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A nurse is caring for a client who is sitting in a chair and asks to return to bed.
Which of the following actions is the nurse's priority?