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

Explanation

The correct answer is A. Instruct the clients to use the call light.

Choice A rationale:

Instructing clients to use the call light ensures they can request assistance before getting up, which is a key strategy in preventing falls, especially during the night when visibility is reduced and the risk of disorientation is higher.

Choice B rationale:

Keeping the clients' rooms dark can increase the risk of falls as it makes it difficult for clients to see obstacles and navigate their environment safely. Adequate lighting is important for fall prevention.

Choice C rationale:

Moving overbed tables away from the bed can actually make it harder for clients to reach essential items and might increase the risk of falls if clients have to stretch or lean awkwardly to get what they need. The overbed table should be positioned within easy reach.

Choice D rationale:

Performing client checks every 4 hours is not frequent enough to effectively monitor at-risk clients. More frequent checks, such as hourly, are recommended to ensure safety and promptly address any needs that could prevent a fall.

A. Family members who smoke must be at least 10 ft from the client when oxygen is in use. B. Nail polish remover or hair spray should not be used near a client who is receiving oxygen. C. A "No Smoking" sign should be placed on the front door. D. Cotton bedding and clothing should be replaced with items made from wool. E. A fire extinguisher should be readily available in the home.

Correct Answer is ["D"]

Explanation

Choice A rationale:

Tying the straps of the restraints in a double knot is incorrect. This action can make it difficult to quickly release the restraints in case of an emergency. A single, quick-release knot is recommended to ensure the client's safety.

Choice B rationale:

Tying the restraints to the side rails is incorrect. Attaching restraints to the side rails can cause injury to the client and is not a proper restraint application method. Restraints should be tied to the bed frame, not the side rails, to prevent harm.

Choice C rationale:

Placing the padding of the restraints against the client's bony prominences is incorrect. While padding is important to prevent skin breakdown and pressure ulcers, the correct placement of the padding alone does not indicate a comprehensive understanding of proper restraint application.

Choice D rationale:

Inserting one finger between the client's wrist and the restraint is the correct action. This technique ensures that the restraints are not too tight, allowing for proper circulation and preventing injury to the client. The ability to insert one finger indicates that the restraints are snug but not constrictive, maintaining the client's safety and comfort.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A night shift nurse works and cares for several clients at risk for falls. Which of the following actions should the nurse take?

Correct Answer is A

Explanation

A nurse is providing reinforcing discharge instructions to a client who has a prescription for oxygen use at home.Which of the following information should the nurse include? (Select all that apply.)

Correct Answer is ["D"]

Explanation

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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?