A nurse is preparing to assist a client out of bed to a wheelchair following left knee surgery. The nurse should identify that which of the following images indicates the correct placement of the wheelchair?

Answer and Explanation

The Correct Answer is C

A. Wheelchair is on the left side, which is the postoperative knee, risking strain or injury to the healing limb during transfer. Not ideal for maximizing client safety and independence in mobility.

B: Wheelchair is placed at the head of the bed, making it impractical and unsafe for transfer. No clear pivot point, and body mechanics would be compromised for both the nurse and the client.

C. The wheelchair is positioned on the client's right side, which is the unaffected leg, allowing the client to pivot and transfer using their stronger limb. This placement minimizes strain on the left surgical knee, which reduces pain and risk of injury.

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Correct Answer is B

Explanation

A. Apply a heating pad to the client's neck: Direct application of heat to the skin, especially in localized areas like the neck, can cause rapid vasodilation, leading to a dangerous drop in blood pressure and potential cardiac complications. It also increases the risk of burns on cold-numbed skin.

B. Provide the client with dry clothing: Removing wet clothing and replacing it with dry garments is the first priority in managing hypothermia. Wet clothes accelerate heat loss through conduction and evaporation. Stopping further heat loss is essential before attempting active rewarming.

C. Offer the client a warm beverage: While offering warm fluids can help increase core temperature and provide comfort, it is not the first priority. This intervention is more appropriate after ensuring the client is dry and wrapped in warm coverings.

D. Wrap the client in warm blankets: Wrapping the client in warm blankets is a critical intervention for passive external rewarming. However, it comes after the initial step of removing wet clothes to prevent ongoing heat loss. Blankets are most effective once the source of heat loss has been eliminated.

A. Remove blankets from the client. B. Place cold packs on the client's axillae. C. Place a fan to blow air across the client. D. Give the client an alcohol sponge bath.

Correct Answer is A

Explanation

A. Removing blankets from the client helps reduce external heat sources and allows body heat to dissipate, which can aid in lowering the elevated temperature. This action supports the body’s natural cooling mechanisms and provides comfort during a febrile state.

B. Placing cold packs on the axillae can help lower body temperature by cooling major blood vessels near the skin’s surface. However, this method may cause discomfort or shivering, which can paradoxically increase metabolic heat production and is less preferred than removing excess coverings.

C. Using a fan to blow air across the client promotes evaporative cooling, but if the client is shivering or chills are present, this can increase discomfort and cause the body to generate more heat. Fans are best used when the client is comfortable and not experiencing chills.

D. Giving an alcohol sponge bath is generally discouraged because alcohol is rapidly absorbed through the skin and can cause toxicity. Additionally, it can cause vasodilation, which might lead to increased heat loss and potential hypothermia if not carefully monitored.

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A nurse is preparing to assist a client out of bed to a wheelchair following left knee surgery. The nurse should identify that which of the following images indicates the correct placement of the wheelchair?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is B

Explanation

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Correct Answer is A

Explanation

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