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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Hyperkalemia is a condition where there is an elevated level of potassium in the blood.
It can occur in patients with renal disease due to the kidneys’ reduced ability to excrete potassium.
Treatment-related side effects, such as certain medications or chemotherapy, can also contribute to hyperkalemia by altering potassium levels in the body1.
Hyperkalemia can lead to life-threatening cardiac conduction disturbances2.
Therefore, it is important for the nurse to determine the apical pulse rate and rhythm.
Choice A is not correct because comparing muscle strength bilaterally is not the most important intervention for a client with a serum potassium level of 7.5 mEq/L (7.5 mmol/L).
Choice C is not correct because measuring color and amount of urine is not the most important intervention for a client with a serum potassium level of 7.5 mEq/L (7.5 mmol/L).
Choice D is not correct because assessing strength of deep tendon reflexes is not the most important intervention for a client with a serum potassium level of 7.5 mEq/L (7.5 mmol/L).
Correct Answer is C
Explanation
This will help determine if there is any residual urine left in the bladder after voiding.
Choice A is not the answer because reviewing the chart for the number of voids over the last 24 hours is important but not sufficient to evaluate for urinary retention.
Choice B is not the answer because evaluating for urinary incontinence is important but not sufficient to evaluate for urinary retention.
Choice D is not the answer because while palpating the suprapubic region for distention can provide some information, scanning the bladder after voiding is a more accurate way to evaluate for urinary retention.
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