A nurse is preparing to transfer a client who weighs 136 kg (300 lb) from a bed to a stretcher with the aid of an assistive personnel (AP). Which of the following actions should the nurse take?

Move the client using a slider board.

Use an air-assisted transfer device to move the client.

Raise the bed to 5 cm (2 in) above the level of the stretcher.

Position the head of the bed at 25° prior to the transfer.

Answer and Explanation

The Correct Answer is B

Choice A rationale:

Moving the client using a slider board might be appropriate for transferring clients with relatively lower weight and mobility challenges. However, in this scenario, where the client weighs 136 kg (300 lb), a more advanced transfer method is necessary to ensure the safety of both the client and the healthcare providers.

Choice B rationale:

Using an air-assisted transfer device is suitable for transferring clients with higher weight, as it helps reduce friction and strain during the transfer process. This approach ensures a smoother transfer and minimizes the risk of injury to both the client and the assistive personnel.

Choice C rationale:

Raising the bed to 5 cm (2 in) above the level of the stretcher might not provide enough clearance for a safe transfer. Additionally, the use of assistive devices is more appropriate for transferring clients with significant weight, rather than relying solely on adjusting the bed height.

Choice D rationale:

Positioning the head of the bed at 25° prior to the transfer is not directly relevant to the process of transferring a client from a bed to a stretcher. The focus should be on using appropriate equipment and techniques for safe and efficient transfer, especially considering the client's weight.

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Correct Answer is A

Explanation

Choosing the best intervention for a client with fever due to infection:

The most appropriate intervention for a client with fever due to infection depends on various factors, including the severity of the fever, the client's age and overall health, and their individual preferences. Let's analyze each option and explain its rationale:

a. Encourage fluid intake of 2,500 mL/day.

Rationale:

Pros:Fever often leads to increased sweating and fluid loss through respiration. Maintaining adequate hydration is crucial to prevent dehydration, which can worsen discomfort and potentially lead to complications like organ dysfunction. Encouraging a fluid intake of 2,500 mL/day is generally recommended for adults with fever, although individual needs may vary based on factors like body size and activity level.
Cons:While hydration is essential, forcing fluids on a client who experiences nausea or vomiting can be counterproductive. Additionally, some clients with certain medical conditions, like heart failure, may require fluid restriction, making this option inappropriate.

b. Maintain the environmental temperature at 16°C to 18°C (60°F to 65°F).

Rationale:

Cons:Excessively cool environments can trigger shivering, which actually increases body heat production and can worsen the fever. Additionally, maintaining such a low room temperature can be uncomfortable for the client and may increase their risk of chills.

c. Immerse the client in cold water.

Rationale:

Cons:Immersing a client in cold water, like a bath, can be a dangerous and counterproductive intervention. The sudden chill can trigger violent shivering, significantly increasing body heat production and potentially causing shock. Moreover, rapid cooling can be uncomfortable and even risky for people with certain health conditions like heart disease.

d. Assist the client to ambulate.

Rationale:

Cons:While ambulation is generally encouraged for healthy clients, it may not be suitable for everyone with a fever. Depending on the severity of the fever and the client's overall condition, ambulation could be tiring and even unsafe. In some cases, rest may be more appropriate to promote comfort and recovery.

Therefore, the most appropriate intervention for a client with fever due to infection is:

a. Encourage fluid intake of 2,500 mL/day.

Remember:

Individualize care based on the client's specific needs and preferences.
Monitor the client's response to interventions and adjust as needed.
Consult with the healthcare provider for guidance on managing the fever and addressing any underlying infection.

A. The nurse administered enoxaparin 40 mg subcutaneous to a client using the deltoid site for injection. B. The nurse advanced the urinary catheter 18 cm (7 in) when inserting an indwelling urinary catheter for a male client. C. The nurse cleanses a wound with 0.99% sodium chloride irrigation prior to collecting a specimen for culture. D. The nurse flushed the tubing of a continuous enteral feeding with 30 mL of water.

Correct Answer is ["A"]

Explanation

The correct answer is Choice A.

Choice A rationale: Administering enoxaparin 40 mg subcutaneously in the deltoid site is incorrect. Enoxaparin is typically administered in the abdomen or thigh to ensure proper absorption and minimize the risk of injury. Administering it in the deltoid requires an incident report for protocol deviation.

Choice B rationale: Advancing the urinary catheter 18 cm (7 in) is standard practice for male clients to ensure the catheter reaches the bladder. There is no indication of error or the need for an incident report as this action follows proper procedure.

Choice C rationale: Cleansing a wound with 0.99% sodium chloride irrigation prior to collecting a specimen for culture is standard practice. This action ensures the wound is free from surface contaminants and does not necessitate an incident report.

Choice D rationale: Flushing the tubing of a continuous enteral feeding with 30 mL of water is standard practice to maintain patency and ensure the effectiveness of the feeding. This procedure follows guidelines and does not require an incident report.

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A nurse is preparing to transfer a client who weighs 136 kg (300 lb) from a bed to a stretcher with the aid of an assistive personnel (AP). Which of the following actions should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is planning care for a client who has a fever due to an infection. Which of the following interventions should the nurse include in the plan of care?

Correct Answer is A

Explanation

Choosing the best intervention for a client with fever due to infection:

A nurse is caring for a group of clients. Which of the following client-care situations requires the nurse to complete an incident report?

Correct Answer is ["A"]

Explanation

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