Proper hand-washing technique requires that a nurse wash for a minimum of what length of time?

30 seconds.

10 seconds.

45 seconds.

20 seconds.

Answer and Explanation

The Correct Answer is D

Choice B rationale:

Call for additional staff to assist with the transfer. The nurse's priority in this situation is ensuring the safety of the client during the transfer from the chair to the bed. Calling for additional staff provides the necessary support to safely move the client, minimizing the risk of falls or injuries. It is crucial to have an adequate number of staff members to assist in transfers, especially when the client's mobility is compromised.

Choice A rationale:

Obtain a walker for the client to use to transfer back to bed. While a walker can be helpful for mobility, the client has already asked to return to bed, indicating the immediate need for assistance. Waiting to obtain a walker could delay the transfer, potentially putting the client at risk.

Choice C rationale:

Use a transfer belt and assist the client back into bed. Using a transfer belt is a suitable technique for assisting clients with mobility. However, the nurse's priority in this scenario is to ensure there is enough staff assistance to guarantee a safe transfer. The nurse should not attempt to perform the transfer alone, even with a transfer belt, as it might be unsafe for both the nurse and the client.

Choice D rationale:

Determine the client's ability to help with the transfer. While assessing the client's ability to participate in the transfer is important, it is not the nurse's priority in this situation. The immediate concern is to secure adequate assistance to safely move the client back to bed.

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Correct Answer is ["D"]

Explanation

Choice A rationale:

Tying the straps of the restraints in a double knot is incorrect. This action can make it difficult to quickly release the restraints in case of an emergency. A single, quick-release knot is recommended to ensure the client's safety.

Choice B rationale:

Tying the restraints to the side rails is incorrect. Attaching restraints to the side rails can cause injury to the client and is not a proper restraint application method. Restraints should be tied to the bed frame, not the side rails, to prevent harm.

Choice C rationale:

Placing the padding of the restraints against the client's bony prominences is incorrect. While padding is important to prevent skin breakdown and pressure ulcers, the correct placement of the padding alone does not indicate a comprehensive understanding of proper restraint application.

Choice D rationale:

Inserting one finger between the client's wrist and the restraint is the correct action. This technique ensures that the restraints are not too tight, allowing for proper circulation and preventing injury to the client. The ability to insert one finger indicates that the restraints are snug but not constrictive, maintaining the client's safety and comfort.

A. The client is expelling too much carbon dioxide. B. The client's blood oxygen level indicates hypoxemia. C. The client has developed an inflammation of the phrenic nerve. D. The client is using his intercostal muscles to breathe.

Correct Answer is C

Explanation

Choice A rationale:

Pulse pressure is the difference between systolic and diastolic blood pressure and is not related to changing positions or the symptoms described in the scenario.

Choice B rationale:

Essential hypertension is a chronic medical condition characterized by elevated blood pressure levels persistently exceeding 140/90 mmHg. It is not directly related to positional changes or postural hypotension symptoms.

Choice C rationale:

Postural (orthostatic) hypotension occurs when a person experiences a sudden drop in blood pressure upon standing up from a sitting or lying position. This drop in blood pressure can lead to symptoms such as dizziness, lightheadedness, and fainting. Slowly changing positions is essential in managing postural hypotension because abrupt movements can worsen these symptoms. Educating the client about the importance of gradual position changes is crucial in preventing or minimizing postural hypotension-related symptoms.

Choice D rationale:

Pre-hypertension refers to blood pressure levels that are higher than normal but not high enough to be diagnosed as hypertension. It does not directly relate to the symptoms described in the scenario.

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Proper hand-washing technique requires that a nurse wash for a minimum of what length of time?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is providing reinforcing discharge instructions to a client who has a prescription for oxygen use at home.Which of the following information should the nurse include? (Select all that apply.)

Correct Answer is ["D"]

Explanation

A nurse explains to a client's family that the client's respirations are faster and deeper than normal because of what?

Correct Answer is C

Explanation

A nurse enters a client's room and sees smoke coming from the client's trash can.Which of the following actions should the nurse take first?

A nurse is caring for a group of clients on an infectious disease unit. The nurse should wear an N95 respirator mask when caring for a client who has which of the following disorders?

A nurse is assessing a sedated client whose respiratory rate has fallen below 10 respirations per minute.The nurse identifies this condition as what?

The nurse is assessing the client's vital signs and is aware that which assessment data requires immediate attention?

A charge nurse is reinforcing teaching for a newly licensed nurse about how to apply wrist restraints for a client.Which of the following actions should the charge nurse identify as an indication that the nurse understands the instructions?

Which medical terminology word part provides the general meaning of the word?

The nurse is assessing the client's vital signs and is aware that which assessment data requires immediate attention?

To accurately take a client's blood pressure, which action by the nurse is most important?