A nurse is observing an assistive personnel (AP) changing the linens on the bed of a client who is immobile. Which of the following actions by the AP should the nurse identify as an indication of the need to intervene?

Rolls the client to one side of the bed

Reaches over the bed to straighten the fitted sheet

Lowers the side rail on the side of the bed closest to the AP

Raises the bed to waist level

Answer and Explanation

The Correct Answer is B

A. Rolling the client to one side of the bed is an appropriate action to change the linens.
B. Reaching over the bed to straighten the fitted sheet can cause strain and potential injury to the AP's back and should be corrected.
C. Lowering the side rail on the side of the bed closest to the AP is necessary for changing the linens safely.
D. Raising the bed to waist level is an appropriate action to ensure proper body mechanics and prevent injury.

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Correct Answer is D

Explanation

A. Driving the client to the emergency department is not appropriate when the client is experiencing symptoms of a potential stroke; immediate medical assessment is needed.
B. Obtaining the telephone number of the client's provider does not address the immediate need for emergency medical care.
C. Finding a location for the client to sit does not address the urgency of the situation; prompt medical attention is crucial.
D. Calling emergency services is the correct action to ensure the woman receives timely medical care for stroke symptoms.

A. Client has a history of alcohol abuse disorder. B. Client has an NG tube to gastric suction. C. Client reports drinking 3.5 to 4 L of water each day. D. Client is currently prescribed spironolactone.

Correct Answer is B

Explanation

A. Alcohol abuse disorder can lead to dehydration and electrolyte imbalances but is not directly linked to low potassium levels.
B. NG tube to gastric suction can lead to potassium loss through gastric secretions, potentially causing hypokalemia.
C. Drinking large amounts of water is not typically associated with low potassium levels; excessive water intake can dilute electrolytes but is less likely to cause hypokalemia.
D. Spironolactone is a potassium-sparing diuretic that can actually increase potassium levels, making it less likely to cause hypokalemia.

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A nurse is observing an assistive personnel (AP) changing the linens on the bed of a client who is immobile. Which of the following actions by the AP should the nurse identify as an indication of the need to intervene?

Nursing Test Bank

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