A nurse is preparing to transfer a client from lying in bed to sitting in a chair. When identifying the safest method of transfer, which of the following is most important for the nurse to determine?

The client's height

The client's ability to communicate

The client's current weight-bearing status

The type of equipment used in previous transfers

Answer and Explanation

The Correct Answer is C

A. Knowing the client's height can be helpful for ergonomic considerations, but it is not critical for the transfer process.

B. The client's ability to communicate is important for understanding their needs and preferences but does not directly impact the physical safety of the transfer.

C. The client's current weight-bearing status is crucial to determine the safest method of transfer. If the client cannot bear weight, additional assistance or equipment may be necessary to prevent falls or injury.

D. While knowing the type of equipment used in previous transfers can provide insight, it is secondary to understanding the client's current physical capabilities and needs.

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Correct Answer is A

Explanation

A. Urinary frequency for several days is an expected outcome after catheter removal, as the bladder may become more sensitive and responsive after having been drained continuously.

B. While temporary urinary retention can occur, it is less common after short-term catheterization, and most clients will start voiding normally within a few hours.

C. Blood-tinged urine may occur occasionally, but it is not a typical expected outcome unless there was trauma or irritation during catheterization.

D. Highly concentrated urine can occur due to dehydration or lack of fluid intake, but it is not a specific expected outcome following catheter removal.

A. Mix the three medications together prior to administering. B. Flush the NG feeding tube with 30 mL of water immediately following medication administration. C. Dilute each medication with 10 mL of tap water. D. Maintain the head of the bed in a flat position for 30 min following medication administration.

Correct Answer is B

Explanation

A. Mixing medications can alter their effectiveness and increase the risk of tube blockage. Each medication should be administered separately.

B. Flushing the NG tube with 30 mL of water after administering medications is important to ensure that the medications are cleared from the tube and absorbed properly by the patient. This also helps to prevent tube occlusion.

C. Diluting medications may not be necessary for all liquid medications, and it depends on the specific medication's guidelines. Each medication should be administered as directed.

D. The head of the bed should be elevated during and after medication administration to prevent aspiration. Keeping it flat is not recommended.

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A nurse is preparing to transfer a client from lying in bed to sitting in a chair. When identifying the safest method of transfer, which of the following is most important for the nurse to determine?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse removes an indwelling urinary catheter that an older adult client has had in place for 2 days. The nurse should assess the client for which of the following expected outcomes after catheter removal?

Correct Answer is A

Explanation

A nurse is preparing to administer three liquid medications to a client who has an NG feeding tube with continuous enteral feedings. Which of the following actions should the nurse take?

Correct Answer is B

Explanation

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