The nurse is demonstrating correct transfer procedures to the unlicensed assistive personnel (UAP) working on a rehabilitation unit. The UAP asks the nurse how to safely move a physically disabled client from the wheelchair to a bed. Which action should the nurse recommend?

Hold the client at arm's length while transferring to better distribute the body weight.

Place the client's locked wheelchair on the client's strong side next to the bed.

Pull the client into position by reaching from the opposite side of the bed.

Apply a gait belt around the client's waist once a standing position has been assumed.

Answer and Explanation

The Correct Answer is B

A. Hold the client at arm's length while transferring to better distribute the body weight: Holding the client at arm's length is not recommended as it does not provide adequate support. The caregiver should be close to the client to maintain control to ensure safe transfer.

B. Place the client's locked wheelchair on the client's strong side next to the bed: Positioning the wheelchair on the client’s strong side provides support and stability during the transfer, allowing the caregiver to assist effectively while ensuring the client’s safety.

C. Pull the client into position by reaching from the opposite side of the bed: Reaching from the opposite side of the bed can cause strain on the caregiver's back and may increase the risk of injury. It is safer to stay close to the client during transfers to minimize physical strain.

D. Apply a gait belt around the client's waist once a standing position has been assumed: The gait belt should be applied before the client assumes a standing position. This ensures proper support and control during the transfer. Waiting until standing could cause instability.

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

Explanation

A. Ask the client if she has any alcohol in the room at this time: This is an essential step in assessing for immediate safety and contraband that may impact her treatment plan, especially considering her symptoms and possible withdrawal risk.

B. Administer a PRN prescription for an antianxiety drug: This could mask symptoms of alcohol withdrawal or interact negatively with alcohol. Medication should be given only after thorough assessment and consultation.

C. Inform the family that they are enabling the client: While family education is important, using accusatory language like "enabling" can damage therapeutic relationships. A nonjudgmental, supportive approach is better.

D. Observe for signs to determine if client is inebriated: Monitoring for inebriation supports accurate clinical assessment and decisions about withdrawal protocols, safety, and medication timing.

E. Schedule a conference with the client and family members: A joint meeting allows open discussion, identifies care goals, and promotes understanding and support from all parties involved.

A. The client with a small bowel obstruction who has a nasogastric tube that is draining greenish fluid. B. The client with a bowel obstruction due to a volvulus who is experiencing abdominal rigidity. C. The client who had surgery yesterday and is experiencing a paralytic ileus with absent bowel sounds. D. The client with an obstruction of the large intestine who is experiencing abdominal distention.

Correct Answer is B

Explanation

A. While the presence of greenish fluid in a nasogastric tube can indicate a small bowel obstruction, this finding alone does not necessarily indicate an immediate life-threatening condition. The client should be monitored, but this is not the priority.

B. Abdominal rigidity in the context of a volvulus (twisting of the bowel) can indicate bowel ischemia or perforation, which is a surgical emergency. Immediate intervention is needed to prevent further complications such as sepsis or peritonitis.

C. A paralytic ileus is a common postoperative complication and often resolves with time. While the absence of bowel sounds is concerning, it is a routine finding in this situation and does not require immediate attention unless there are signs of further complications.

D. Abdominal distention in a large bowel obstruction can indicate a need for further assessment and treatment. However, compared to a volvulus with abdominal rigidity, this situation is less urgent and does not represent an immediate life-threatening emergency.

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The nurse is demonstrating correct transfer procedures to the unlicensed assistive personnel (UAP) working on a rehabilitation unit. The UAP asks the nurse how to safely move a physically disabled client from the wheelchair to a bed. Which action should the nurse recommend?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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

Explanation

After receiving report on an inpatient acute care unit, which client should the nurse assess first?

Correct Answer is B

Explanation

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