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 ["A","B","E"]

Explanation

Choice A rationale:

Drinking something cold can lower the oral temperature temporarily. When a person consumes something cold, the blood vessels in the mouth can constrict, leading to a lower temperature reading. However, it's important to note that this effect is temporary.

Choice B rationale:

Exercising can increase blood circulation and raise body temperature. However, immediately after intense physical activity, the body might start sweating, leading to a temporary drop in temperature. Prolonged or moderate exercise, on the other hand, generally increases body temperature.

Choice C rationale:

An outdoor temperature of 99°F does not directly affect body temperature. Body temperature is regulated internally and does not fluctuate based on external temperatures unless the person is exposed to extreme conditions for a prolonged period.

Choice D rationale:

A cold climate might lower skin temperature, but it does not necessarily reduce the body's core temperature significantly. The body has mechanisms to conserve heat in colder environments.

Choice E rationale:

Physical inactivity can lower body temperature, especially in situations where the person is sedentary for an extended period. Reduced physical activity can slow down metabolic processes, leading to a lower body temperature.

A. Counting a regular pulse for 30 seconds and doubling the number to obtain the rate. B. Palpates the femoral artery in the groin of the client. C. Palpates both carotid pulses at the same time. D. Palpates the radial artery on the thumb side of the wrist.

Correct Answer is A

Explanation

Choice A rationale:

The client's respirations are faster and deeper than normal due to expelling too much carbon dioxide. This condition is known as hyperventilation. Hyperventilation can occur due to various reasons such as anxiety, pain, fever, or metabolic acidosis. When the body expels excessive carbon dioxide, it leads to respiratory alkalosis, resulting in faster and deeper breathing to compensate for the decrease in carbon dioxide levels in the blood.

Choice B rationale:

This option is incorrect. Hypoxemia, or low blood oxygen levels, typically leads to rapid, shallow breathing (tachypnea) rather than deep and fast respirations.

Choice C rationale:

This option is incorrect. Inflammation of the phrenic nerve does not directly affect the depth and rate of respirations. Phrenic nerve inflammation is more likely to cause pain during breathing or hiccups.

Choice D rationale:

This option is incorrect. Using intercostal muscles to breathe is a normal physiological process, especially during deep or labored breathing. However, it does not explain the specific situation described in the question, where the respirations are faster and deeper than normal.

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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?