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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason: This is the correct action as it prevents the risk of spillage, scalding, or infection. The basin of water should not be placed on the bed, but on a bedside table or stand. The nurse should also check the temperature of the water and the condition of the client's foot.
Choice B reason: This is an incorrect action as it may cause irritation or allergic reaction. The skin cream should not be added to the basin of water, but applied after the foot is dried and inspected. The nurse should also verify the type and amount of skin cream to be used.
Choice C reason: This is an important action, but not the priority. The UAP should dry between the client's toes completely to prevent fungal growth or maceration. The nurse should also monitor the UAP's technique and provide feedback.
Choice D reason: This is an inaccurate statement. The procedure of soaking the client's foot in a basin of warm water is not damaging to the skin, if done properly and safely. The nurse should explain the rationale and benefits of the procedure to the UAP.
Correct Answer is A
Explanation
Choice A reason: Smoking cessation is the most important lifestyle modification for the nurse to encourage. Smoking is a major risk factor for cardiac disease, as it increases blood pressure, heart rate, and oxygen demand, and damages the blood vessels and the heart muscle. Quitting smoking can reduce the risk of cardiac disease by 50% within one year.
Choice B reason: Regular exercise is a beneficial lifestyle modification for the nurse to encourage, but not the most important one. Exercise can improve cardiovascular fitness, lower blood pressure, and reduce body weight, but it does not eliminate the harmful effects of smoking on the heart and blood vessels.
Choice C reason: A low-fat diet is a helpful lifestyle modification for the nurse to encourage, but not the most important one. A low-fat diet can lower cholesterol levels and prevent atherosclerosis, but it does not reverse the damage caused by smoking to the heart and blood vessels.
Choice D reason: Stress reduction is a useful lifestyle modification for the nurse to encourage, but not the most important one. Stress can trigger the release of hormones that increase blood pressure, heart rate, and oxygen demand, and can also lead to unhealthy behaviors such as smoking, overeating, and alcohol abuse. However, stress reduction alone does not address the direct effects of smoking on the heart and blood vessels.
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