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 A

Explanation

Choice A reason: Providing oral sponge toothettes is the best action to take. It helps the client to maintain oral hygiene and comfort, and prevents dryness and cracking of the oral mucosa.

Choice B reason: Teaching the client that the oral mucosa must remain dry to prevent aspiration is not a correct action. The oral mucosa needs to be moist to protect it from infection and irritation. Aspiration is prevented by checking the placement of the nasogastric tube and keeping the head of the bed elevated.

Choice C reason: Turning the suction off while allowing the client to rinse his mouth with cool water is not a safe action. It may increase the risk of aspiration and interfere with the function of the nasogastric tube. The suction should only be turned off when necessary, such as during medication administration or tube feeding.

Choice D reason: Instilling 50 ml of normal saline solution into the tube and clamping the tube for one hour is not an appropriate action. It may cause fluid overload, electrolyte imbalance, and abdominal distension. The nasogastric tube should be flushed with 30 ml of water every 4 to 6 hours to maintain patency and prevent clogging.

A. "The healthcare provider will share this information with you." B. "I can give you those results as soon as I get them back from the lab." C. "I'm sorry, but your child's medical information is none of your business." D. "I can only give medical information to your child because they are legally an adult."

Correct Answer is D

Explanation

Choice A reason: This is an incorrect response as it implies that the healthcare provider will disclose the client's laboratory results to the parents. However, the client is emancipated and has the right to privacy and confidentiality of their medical information. The nurse should respect the client's autonomy and consent.

Choice B reason: This is an incorrect response as it implies that the nurse will share the client's laboratory results with the parents. However, the client is emancipated and has the right to privacy and confidentiality of their medical information. The nurse should respect the client's autonomy and consent.

Choice C reason: This is an incorrect and rude response as it insults the parents and disregards their concern. The nurse should be polite and professional when communicating with the parents. The nurse should explain the legal and ethical reasons for not disclosing the client's medical information.

Choice D reason: This is the correct and respectful response as it informs the parents that the client is emancipated and has the right to privacy and confidentiality of their medical information. The nurse should respect the client's autonomy and consent and only give medical information to the client or their designated representative.

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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

A male client with a nasogastric tube connected to low intermittent suction tells the nurse that his mouth is very dry. Which action should the nurse implement?

Correct Answer is A

Explanation

A 16-year-old emancipated client is being seen in the emergency department following a minor automobile accident. The client's parents arrive and are asking questions about the client's laboratory results. Which response is best for the nurse to provide?

Correct Answer is D

Explanation

The nurse is evaluating the fluid balance of a client who was admitted yesterday with dehydration and who has been receiving IV fluids since admission. An increase in which parameter indicates to the nurse that the client is rehydrating?

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A client who had surgery 3 days ago is sitting with the head of the bed at 75 degrees and requests to be repositioned. Which instruction is most important for the nurse to provide to the unlicensed assistive personnel (UAP)?

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The nurse observes an unlicensed assistive personnel (UAP) who is providing a total bed bath for a confused and lethargic client. The UAP is soaking the client's foot in a basin of warm water placed on the bed. Which action should the nurse take?

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The practical nurse (PN) applies sterile gloves and opens a pack of sterile sponges to assist the healthcare provider with a bedside procedure. After the charge nurse observes the PN, which action should the charge nurse take?

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