A nurse is preparing to transfer a client who has left-sided weakness from a sitting position in bed to a chair. Which of the following actions should the nurse take?
Place the chair on the client's left side.
Raise the height of the client's bed.
Lock the wheels on the client's bed.
Place the chair at a 90° angle to the bed.
The Correct Answer is C
A) The chair should be placed on the client's stronger (right) side to facilitate a safer and more controlled transfer. The client can use their stronger side to assist in the movement.
B) The bed should be at a comfortable height, ideally level with the chair, to allow a smooth transfer. Raising the bed too high can make it difficult for the client to place their feet firmly on the ground, reducing stability.
C) Locking the wheels on the bed ensures stability and prevents movement while assisting the client with the transfer. This is a crucial safety measure to reduce the risk of falls or injuries during the transfer process.
D) The chair should be positioned at a 45° angle to the bed to allow for a more natural pivot and smoother transfer. A 90° angle can make the movement more difficult and awkward for the client.
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Related Questions
Correct Answer is D
Explanation
A) Urine retention is a common symptom of bladder outlet obstruction but in this case assessing the patient for a urinary tract infection is the priority.
B) While proteinuria can indicate kidney dysfunction, it's not directly related to urinary retention.
C) This refers to bladder dysfunction due to neurological causes and may not be directly related to urinary retention in an immobile client.
D) Immobility can increase the risk of urinary tract infections Urinary retention can lead to urinary tract infection (UTI) due to bacterial growth in the stagnant urine. The nurse should monitor the client for signs and symptoms of UTI, such as fever, chills, dysuria, hematuria, and foul-smelling urine.
Correct Answer is B
Explanation
A) Orthostatic hypotension primarily affects blood pressure regulation and is not directly related to the risk of pulmonary emboli.
B) Orthostatic hypotension can cause dizziness and fainting upon standing, increasing the risk of falls.
C) Orthostatic hypotension is typically indicated by a decrease in systolic blood pressure of 20 mm Hg or more.
D) Orthostatic hypotension is primarily diagnosed based on changes in systolic blood pressure, not diastolic blood pressure.
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