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: Completing an adverse occurrence/incident report is not the most important action to implement. It may be necessary to document the incident later, but it does not address the immediate safety issue of the client.

Choice B reason: Demonstrating proper securing of the restraints is the best action to implement. It corrects the mistake made by the UAP and ensures that the client is not at risk of injury or entrapment. It also educates the UAP on the correct technique and policy for applying restraints.

Choice C reason: Ensuring that the restraints are not too tight is a relevant action to implement, but not the most important one. It is part of the ongoing assessment and care of the client who is restrained, but it does not correct the improper securing of the restraints to the bedside rails.

Choice D reason: Initiating the facility's restraint flow sheet is a required action to implement, but not the most important one. It is part of the documentation and evaluation of the client who is restrained, but it does not address the immediate safety issue of the client.

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

The nurse observes the unlicensed assistive personnel (UAP) securing a client's wrist restraints to the bedside rails. Which action is most important for the nurse to implement?

Correct Answer is B

Explanation

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Correct Answer is D

Explanation

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