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 B

Explanation

If a nurse observes that a client is using accessory muscles, it indicates an obstruction of the airways, which reduces oxygen saturation.

Accessory muscles help in the act of forced expiration to wash out carbon dioxide and improve oxygen saturation 1.

Therefore, the nurse should obtain the respiratory rate first.

Choice A is not the answer because determining pulse pressure will not provide any significant indication of respiratory distress 1.

Choice C is not the answer because temperature does not provide any significant data about the use of accessory muscles in respiration 1.

Choice D is not the answer because pulse rate does not provide any significant data about the use of accessory muscles in respiration 1.

A. Elevate the head of the bed to a 45-degree angle B. Apply the client's positive airway pressure device C. Lift and lock the side rails in place D. Remove dentures or other oral appliances

Correct Answer is B

Explanation

The client has difficulty sleeping due to obstructive sleep apnea (OSA), and using a positive airway pressure device can help keep their airway open and prevent dangerous pauses in breathing while they sleep 1.

Choice A is not the answer because elevating the head of the bed to a 45-degree angle may provide some relief for OSA, but it is not as effective as using a positive airway pressure device 1.

Choice C is not the answer because lifting and locking the side rails in place is a safety measure but does not directly address the client’s OSA 1.

Choice D is not the answer because removing dentures or other oral appliances may provide some relief for OSA, but it is not as effective as using a positive airway pressure device 1.

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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

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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?