An unlicensed assistive personnel (UAP) is assigned to provide personal care for a client who is prescribed bedrest with bedside commode use. The UAP reports to the nurse that the client's obesity makes it difficult to safely assist the client in transferring from the bed to the bedside commode. How should the nurse respond?

Advise the client to maintain bedrest to ensure safety.

Instruct the UAP that all clients deserve equal care.

Determine the client's level of mobility and need for assistance.

Assign another UAP to care for the client.

Answer and Explanation

The Correct Answer is C

Choice A reason: Advising the client to maintain bedrest may not be practical or beneficial for the client's overall health and does not address the UAP's concern about safe transfer.

Choice B reason: While it is true that all clients deserve equal care, this statement does not provide a solution to the UAP's concern about safely assisting the client.

Choice C reason: Determining the client's level of mobility and need for assistance will help in creating a safe and effective plan for transferring the client to the bedside commode.

Choice D reason: Assigning another UAP may be necessary if the current UAP is unable to assist safely, but it is not the first step. The nurse should first assess the situation before making staffing changes.

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Correct Answer is B

Explanation

Choice A reason: While nutrition is important, a high-protein diet is not specific to the management of heart failure.

Choice B reason: Weighing every morning allows for monitoring of fluid retention, which is a key aspect of managing heart failure.

Choice C reason: Range of motion exercises are good for overall health but are not specific to heart failure management.

Choice D reason: Limiting fluid intake is important, but it is more critical to monitor weight daily to detect fluid retention early.

A. Obtain a history of allergic reactions B. Document lying, sitting, and standing blood pressures C. Perform a mini mental exam on the child D. Determine when the child last ate E. Locate and mark the pedal pulses F. Measure the child’s height and weight

Correct Answer is ["A","B","D","E"]

Explanation

Choice A reason: Obtaining a history of allergic reactions is crucial because the child will be exposed to various substances during cardiac catheterization, such as contrast dye, which could potentially cause an allergic reaction.
Choice B reason: Documenting lying, sitting, and standing blood pressures is important to assess for orthostatic hypotension, which could indicate volume depletion or cardiovascular problems that need to be addressed before the procedure.
Choice C reason: Performing a mini mental exam on the child is not typically part of the pre-procedure assessment for cardiac catheterization, especially given the young age of the child.
Choice D reason: Determining when the child last ate is essential because the child needs to have an empty stomach to reduce the risk of aspiration during sedation.
Choice E reason: Locating and marking the pedal pulses is important to establish baseline data so that post-procedure, any changes in the strength or presence of these pulses can be quickly identified, indicating potential complications.
Choice F reason: Measuring the child’s height and weight is generally part of a routine assessment but is not specifically focused on the pre-cardiac catheterization assessment unless dosing of medication or anesthesia is required based on weight.

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Naxlex Comprehensive Predictor Exams

A client is being discharged home after being treated for heart failure (HF). Which instruction should the nurse include in this client's discharge teaching plan?

Correct Answer is B

Explanation

Patient Data Exhibits Based on the results of the echocardiogram, the physician has decided to repair the ventricular septal defect via cardiac catheterization. What should the nurse’s focused assessment include before the cardiac catheterization? Select all that apply.

Correct Answer is ["A","B","D","E"]

Explanation

A client with bladder cancer had surgical placement of a ureter ileostomy (ileal conduit) yesterday. Which postoperative assessment finding should the nurse report to the healthcare provider immediately?

Patient Data Exhibits What can the nurse do to help the parents decrease their anxiety? Select all that apply.

The nurse is teaching a client with early osteoporosis the importance of including vitamin D with calcium supplements. Which information is most important for the nurse to provide to encourage the client's compliance in the management of progressing osteoporosis?

When performing suctioning for a client with a tracheostomy, which action should the nurse include?

A nurse is caring for a client with binge eating disorder. Which goal should the nurse establish first with the client?

A client who is one day postpartum reports to the nurse that her baby cannot latch onto the breast. The nurse observes that the client's nipples are inverted. Which action should the nurse implement?