A nurse is preparing to move a client who is only partially able to assist up in bed. Which of the following methods should the nurse plan to use?

One nurse lifting as the client pushes with his feet

Two nurses lifting the client under the shoulders

Two nurses using a friction-reducing device

One nurse lifting the client's legs as the client uses a trapeze bar

Answer and Explanation

The Correct Answer is C

A.   Having one nurse lift as the client pushes with his feet may not provide enough support and could potentially lead to an unsafe transfer, especially if the client is only partially able to assist.
B.   Lifting the client under the shoulders with the assistance of another nurse may be appropriate for a different type of transfer, such as a sit-to-stand transfer, but it may not be the most suitable method for moving the client up in bed.
C.   When a client is only partially able to assist, using a friction-reducing device, such as a slide or transfer board, is an effective and safe method. This device helps reduce the
friction between the client and the bed, making it easier to move the client up in bed.
D.   Using a trapeze bar requires the client to have a certain level of strength and mobility, and may not be suitable for a client who is only partially able to assist.

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Correct Answer is B

Explanation

A. After palpating the abdomen is not the ideal time to auscultate bowel sounds.
Palpation may stimulate bowel sounds and potentially give a false impression of their presence or absence.
B. Prior to percussing the abdomen is the correct sequence. Auscultation of bowel sounds should be done before any other abdominal assessment techniques, including percussion or palpation. This allows the nurse to accurately hear any existing bowel sounds without interference.
C. Prior to inspecting the abdomen is not the ideal time for auscultation. Inspection focuses on visual examination and assessment, which does not involve listening for bowel sounds.
D. After assessing for kidney tenderness is not the correct timing for auscultating bowel sounds. Assessing for kidney tenderness involves a different aspect of the physical examination and does not influence bowel sound assessment.

A. Checking the pupillary response to light B. Eliciting the gag reflex C. Testing visual acuity D. Observing for facial symmetry

Correct Answer is A

Explanation

A. Cranial nerve III, also known as the oculomotor nerve, controls the muscles that move the eye and regulates the size of the pupil. Assessing the pupillary response to light helps evaluate the function of this nerve.
B. Eliciting the gag reflex is associated with cranial nerves IX (glossopharyngeal) and X (vagus), not cranial nerve III.
C. Testing visual acuity is primarily associated with cranial nerve II (optic nerve), not cranial nerve III.
D. Observing facial symmetry is important for assessing cranial nerve VII (facial nerve), not cranial nerve III.

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A nurse is preparing to move a client who is only partially able to assist up in bed. Which of the following methods should the nurse plan to use?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assessing a client's bowel sounds. At which of the following points in the assessment should the nurse auscultate the client's abdomen?

Correct Answer is B

Explanation

A nurse is assessing a client's cranial nerves as part of a neurological examination. Which of the following actions should the nurse take to assess cranial nerve III?

Correct Answer is A

Explanation

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