After a week of bedrest, 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. Which action should the nurse implement next?

Offer a pair of non-skid socks.

Place the chair by the bed.

Support the client when rising.

Determine how the client feels.

Answer and Explanation

The Correct Answer is C

Choice A reason: Offering a pair of non-skid socks is not the most important action to implement next. The client may already have non-skid socks on, or may not need them if they are not walking. The priority is to prevent falls and injuries when transferring the client to the chair.

Choice B reason: Placing the chair by the bed is a necessary action to implement, but not the next one. The chair should already be by the bed before the nurse raises the head of the bed and moves the client to a sitting position. The next action is to help the client stand up and move to the chair.

Choice C reason: Supporting the client when rising is the best action to implement next. The client may be weak, dizzy, or unsteady after a week of bedrest, and may need assistance to stand up and sit down. The nurse should use proper body mechanics and a transfer belt if needed to support the client.

Choice D reason: Determining how the client feels is a relevant action to implement, but not the next one. The nurse should assess the client's vital signs, comfort, and tolerance of the activity after transferring the client to the chair. The next action is to ensure the client's safety and stability.

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Correct Answer is B

Explanation

Choice A reason: Serum potassium and sodium levels are not relevant to the assessment of the wound infection. They are electrolytes that regulate fluid balance, nerve conduction, and muscle contraction. They may be affected by dehydration, renal failure, or diuretics.

Choice B reason: Neutrophil count is the most relevant laboratory value to note before reporting the wound infection. Neutrophils are white blood cells that fight bacterial infections and inflammation. A high neutrophil count indicates an acute infection or inflammation, while a low neutrophil count indicates a compromised immune system or a chronic infection.

Choice C reason: Blood pH level is not relevant to the assessment of the wound infection. It is a measure of the acidity or alkalinity of the blood. It may be affected by respiratory or metabolic disorders, such as acidosis or alkalosis.

Choice D reason: Hematocrit is not relevant to the assessment of the wound infection. It is the percentage of red blood cells in the blood. It may be affected by anemia, dehydration, or polycythemia.

A. Consult with the dietitian to learn if the client is allowed to drink coffee. B. Remind the client that no milk or creamer can be added to the coffee. C. Determine which member of the nursing staff brought the cup of coffee to the client. D. Remove the coffee from the tray, advising the client that it is not included in the diet.

Correct Answer is B

Explanation

Choice A reason: Consulting with the dietitian to learn if the client is allowed to drink coffee is not the best action to take. The nurse should already know the components of a clear liquid diet, which do not include coffee. Coffee is a stimulant that can irritate the gastrointestinal tract and interfere with the healing process.

Choice B reason:This is the correct action. A clear liquid diet allows for transparent liquids that leave no residue, such as black coffee. Adding milk or creamer would render the coffee opaque, making it unsuitable for a clear liquid diet. Therefore, it's appropriate to remind the client to consume the coffee without any additives.

Choice C reason: Determining which member of the nursing staff brought the cup of coffee to the client is not a priority action to take. The nurse should focus on the client's safety and well-being, not on assigning blame or finding fault. The nurse can address the issue with the staff later, after ensuring the client's needs are met.

Choice D reason: Removing the coffee is unnecessary, as black coffee is permitted on a clear liquid diet. Instead, the nurse should ensure the client understands not to add any prohibited substances like milk or creamer.

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After a week of bedrest, 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. Which action should the nurse implement next?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

While changing the dressing of a client with a leg ulcer, the nurse observes a red, tender, and swollen wound at the site of the lesion. Before reporting this finding to the healthcare provider, the nurse should note which of the client's laboratory values?

Correct Answer is B

Explanation

The nurse observes that a client on a clear liquid diet has a cup of coffee on the breakfast tray. Which action should the nurse implement?

Correct Answer is B

Explanation

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