The nurse enters the room of an older adult client and observes the client positioned in a wheelchair as seen in the picture. The unlicensed assistive personnel (UAP) is preparing to push the client's wheelchair in the hallway. Which instruction should the nurse provide the UAP before the client is moved into the hallway?

Use a belt restraint to secure the client in the chair.

Empty the client's urinary drainage bag.

Reposition the client's urinary drainage bag.

Elevate the client's feet higher on the foot rests.

Answer and Explanation

The Correct Answer is C

A.   Using a belt restraint is generally not recommended unless specifically ordered for safety reasons, as it may not be appropriate or necessary in all cases. Restraints should only be used when absolutely needed and when all other methods of ensuring safety have been considered.
B.   Emptying the urinary drainage bag before moving the client is important to prevent overflows and ensure that the bag does not become a source of discomfort or potential infection. However, this step might not always be immediately necessary unless the bag is full or the client’s comfort and hygiene are at risk.
C.   Repositioning the urinary drainage bag is crucial for ensuring that the bag remains below the level of the bladder and is not subject to kinks or obstructions. This helps prevent backflow and potential infections. Proper positioning also contributes to the client’s comfort and dignity, making this a priority before moving the client.
D.   Elevating the client’s feet on the footrests is important for their comfort and to prevent swelling or pressure sores, especially if the client has limited mobility or circulatory issues. Proper positioning can prevent discomfort and promote better circulation, which is essential for maintaining the client’s well- being during transport.

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Correct Answer is B

Explanation

A. Infection in the lower leg could cause localized redness, swelling, warmth, and possibly pain. However, the presence of these symptoms alone is not as specific to infection, especially without additional symptoms like fever or purulent discharge.
B. Deep vein thrombosis is a condition where a blood clot forms in a deep vein, commonly in the legs. The symptoms of DVT include swelling (edema), redness (erythema), warmth, and sometimes pain in the affected leg. Given that the client has paresis on one side and is likely less mobile, the risk of DVT increases.
C. A pulmonary embolism occurs when a blood clot (often from the legs) travels to the lungs and causes a blockage. While a pulmonary embolism is a serious complication of DVT, the findings of localized edema and erythema in the leg are more directly associated with DVT itself rather than the secondary complication of a pulmonary embolism.
D. Fat emboli typically occur after fractures or trauma and lead to fat droplets entering the bloodstream and causing blockages in the lungs, brain, or skin. The classic symptoms include respiratory distress, neurological symptoms, and petechial rash.

A. Notify the hospital ethical committee to assist with client's wishes. B. Have resuscitation equipment readily available. C. Document healthcare provider's refusal to honor client's wishes. D. Facilitate a meeting between the healthcare provider and the spouse.

Correct Answer is A

Explanation

A. The ethics committee can provide guidance on how to navigate the conflict between the healthcare provider’s beliefs and the client's documented wishes. The committee can mediate discussions and help ensure that the client's rights and preferences are respected according to legal and ethical standards.
B. While having resuscitation equipment available might be relevant if there is a sudden need for emergency intervention, it does not directly address the issue of honoring the client’s living will. This action does not resolve the ethical conflict or ensure that the client’s wishes are respected.
C. Documenting the healthcare provider’s refusal is important for legal and medical records but does not resolve the situation or ensure that the client’s wishes are respected. Documentation alone does not address the ethical conflict or take action to honor the client’s living will.
D. Facilitating a meeting between the healthcare provider and the spouse could be beneficial for discussing the client’s wishes and potentially reaching a mutual understanding. However, if the healthcare provider remains unwilling to honor the living will despite such discussions, this action alone may not resolve the conflict.

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Naxlex Comprehensive Predictor Exams

An older client is hospitalized following an embolic stroke resulting in right-sided paresis. Three days after admission, the nurse notes edema and erythema to the right lower leg. These findings should alert the nurse to which possible condition?

Correct Answer is B

Explanation

Correct Answer is A

Explanation

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A client is having trouble breathing while lying in a dorsal recumbent position. Which action should the nurse implement first?

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