After a week of bed rest, a client is being assisted to a chair for the first time.
The nurse raises the head of the bed and moves the client to a sitting position. What should the nurse implement next?

Determine how the client feels.

Support the client when rising.

Offer a pair of non-skid socks.

Place the chair by the bed.

Answer and Explanation

The Correct Answer is A

After moving the client to a sitting position, the next step the nurse should implement is to determine how the client feels.

This allows the nurse to assess for any dizziness, lightheadedness, or other symptoms that may indicate orthostatic hypotension or other issues.

Choice B, supporting the client when rising, is important but should be done after assessing how the client feels.

Choice C, offering a pair of non-skid socks, may be helpful for safety but is not the most important action in this situation.

Choice D, placing the chair by the bed, should be done before moving the client to a sitting position.

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Correct Answer is A

Explanation

Charting by exception means that the nurse only documents findings that deviate from the established norm or expected outcome.

In this case, the nurse should document the assessment that is not within normal limits, which is “Basilar lung sounds that are diminished in the left lung.”

Choice B is not the answer because contraction of the left pupil when light shines in the right eye is a normal finding known as consensual pupillary response.

Choice C is not the answer because capillary refill of 2 seconds in the lower right foot is a normal finding.

Choice D is not the answer because active bowel sounds in the lower right quadrant are a normal finding.

A. Shares the health history with case manager. B. Discusses diagnoses with the physical therapist. C. Provides a list of food allergies to nutritional services. D. Requests military records by phone.

Correct Answer is D

Explanation

Requesting military records by phone without the patient’s consent would be a breach of confidentiality.

Choice A is incorrect because sharing the health history with a case manager who is involved in the patient’s care would not be a breach of confidentiality.

Choice B is incorrect because discussing diagnoses with a physical therapist who is involved in the patient’s care would not be a breach of confidentiality.

Choice C is incorrect because providing a list of food allergies to nutritional services who are involved in the patient’s care would not be a breach of confidentiality.

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After a week of bed rest, a client is being assisted to a chair for the first time. The nurse raises the head of the bed and moves the client to a sitting position. What should the nurse implement next?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A healthcare organization requires nurses to chart by exception. Which assessment should the nurse document?

Correct Answer is A

Explanation

The charge nurse is assisting a nurse in the admission process for a patient with multiple chronic conditions. Which action taken by the nurse demonstrates a breach of confidentiality to the charge nurse?

Correct Answer is D

Explanation

After a week of bed rest, a client is being assisted to a chair for the first time. The nurse raises the head of the bed and moves the client to a sitting position. What should the nurse implement next?

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After a week of bed rest, a client is being assisted to a chair for the first time.
The nurse raises the head of the bed and moves the client to a sitting position. What should the nurse implement next?