A nurse is preparing to obtain a health history from a client who is on bedrest. Which of the following positions should the nurse take to place the client at ease?

Sit in a chair next to the bed.

Sit on the bed next to the client.

Stand at the side of the bed.

Stand at the foot of the bed.

Answer and Explanation

The Correct Answer is A

A.   Sitting in a chair next to the bed provides a comfortable and professional setting, allowing the nurse to engage with the client at eye level.
B.   Sitting on the bed may be seen as too informal and might invade the client’s personal space.
C.   Standing at the side of the bed can create a sense of distance and is less personal.
D.   Standing at the foot of the bed may make the nurse seem detached and less approachable.

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Correct Answer is D

Explanation

A. Withdrawal from pain would indicate a lower Glasgow coma scale rating and a lower level of consciousness.
B. Opening eyes to sound also indicates a reduced level of consciousness.
C. An inability to obey commands would result in a lower GCS score.
D. A GCS rating of 15 means the client is fully alert and oriented to person, place, and time, which corresponds with orientation times three.

A. Insert a large-bore IV catheter. B. Witness the client signing a consent for transfusion. C. Flush the transfusion tubing with dextrose 5% in water. D. Explain to the client that transfusion reactions are not serious. E. Have a second nurse confirm the information on the blood label.

Correct Answer is ["A","B","E"]

Explanation

Correct actions;
A. A large-bore IV catheter is recommended for blood transfusions because it allows for faster and more efficient administration of the blood product. Blood transfusions require proper blood flow to prevent damage to the blood cells, and a larger catheter (usually 18 or 20 gauge) ensures this. A smaller catheter may increase the risk of hemolysis (destruction of red blood cells) or slower transfusion rates, which is not ideal in an emergency situation.
B. It is mandatory to obtain informed consent before any transfusion procedure. The nurse is required to witness the client’s signature on the consent form, ensuring that the client understands the procedure, risks, and benefits. The client’s statement of concern ("I'm really scared...") emphasizes the importance of having a thorough discussion and ensuring they understand what is happening.
E. Two nurses must independently verify the blood product details (such as the blood type and matching the client’s identification) before the transfusion begins. This double-checking procedure is a safety protocol to prevent transfusion errors, such as administering the wrong blood type, which can lead to severe reactions and complications.
Incorrect actions:
C. Dextrose solutions (D5W) should not be used to flush blood transfusion tubing. This is because dextrose solutions can cause hemolysis (destruction of red blood cells) when mixed with blood. The correct solution to flush blood transfusion lines is normal saline (0.9% sodium chloride), as it is compatible with blood products and helps prevent damage to the red blood cells.
D. Transfusion reactions, although rare, can be serious and even life-threatening. It is important for the nurse to provide accurate and clear information about potential transfusion reactions (e.g., allergic reactions, fever, hemolytic reactions, anaphylaxis) and to educate the client on what to expect

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System	Findings
General	Adult child accompanying parent reports decline in client, expressing concern over memory and thought process, appetite, and self-care. Adult child states, "My sibling and I hired help at home for my parent. We thought that would help but it has not. I found the title to the car today, signed over to me."
Physical	Client makes poor eye contact, speaks in a monotone voice, and has a lack of facial expression. Client reports sleeping 7 hr a night and getting up "once or twice per night to go to the bathroom." Client reports not wanting to eat anymore. Client's child reports their parent has lost about 8 lb in the past month. Heart rate 68/min
Affect	Client says, "Why don't you just leave me? I am of no use."

A nurse is preparing to obtain a health history from a client who is on bedrest. Which of the following positions should the nurse take to place the client at ease?

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Naxlex Comprehensive Predictor Exams

A nurse in an emergency department is caring for a client following a motor vehicle crash. The client's Glasgow coma scale rating is 15. Which of the following findings should the nurse expect?

Correct Answer is D

Explanation

Exhibits The nurse reviews the entries in the medical record. The nurse is preparing the client for a blood transfusion. Which of the following actions should the nurse take? Select all that apply.

Correct Answer is ["A","B","E"]

Explanation

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