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

Explanation

A. Palpate the client's suprapubic area for distention: The symptoms suggest possible urinary retention, which could be a result of benign prostatic hyperplasia (BPH) or another obstruction. Palpating the suprapubic area for distention is important to assess for urinary retention and determine if the bladder is full.

B. Obtain a urine specimen for culture and sensitivity: Although a urinary tract infection can cause urinary symptoms, the client's presentation is more likely indicative of a physical obstruction such as BPH. A culture might be needed later if infection is suspected.

C. Instruct in effective techniques to cleanse the glans penis: Proper hygiene is important, especially in older adult men, but this is not the most relevant action for the symptoms described. The focus should be on assessing for possible urinary retention or obstruction.

D. Advise the client to maintain a voiding diary for one week: While a voiding diary may provide useful information for monitoring symptoms over time, the immediate priority is to assess for urinary retention and bladder distention.

A. Type of anticonvulsant prescribed. B. History of a recent illness. C. Therapeutic level of medication. D. Duration of previous seizure activity.

Correct Answer is C

Explanation

A. Type of anticonvulsant prescribed: While the class or type of anticonvulsant influences seizure control, it does not directly indicate whether the client is receiving a sufficient dosage. The therapeutic effectiveness depends more on blood concentration than classification.

B. History of a recent illness: Acute illness can temporarily lower the seizure threshold, but it is a less specific indicator for predicting recurrence than pharmacologic control. The underlying condition must be assessed, but medication levels are more predictive of seizure risk.

C. Therapeutic level of medication: A subtherapeutic drug level is a strong predictor of seizure recurrence. Maintaining an adequate plasma concentration ensures optimal seizure control and is crucial in clients recovering from status epilepticus, where precise management is essential.

D. Duration of previous seizure activity: The length of the prior seizure can indicate severity but not the likelihood of recurrence. Even brief seizures can recur if anticonvulsant levels are inadequate, so duration is not as clinically useful as drug level monitoring.

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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

An older adult male client arrives at the clinic reporting that his bladder always feels full. The client also reports a weak urine flow, frequent dribbling after voiding, and increasing nocturia with difficulty initiating the urine stream. Which action should the nurse implement?

Correct Answer is A

Explanation

A client who is admitted after an episode of status epilepticus is stabilized. Which finding should the nurse use to determine the client's risk for recurrence of seizure activity?

Correct Answer is C

Explanation

A parent brings their child, who has a history of asthma, to the emergency room. The child is wheezing and speaking one word between each breath. The child is anxious, tachycardic, and has labored respirations. Which assessment is most important for the nurse to obtain?

Which laboratory values are critical for the nurse to monitor for a client who is experiencing a thyrotoxic crisis?

A client with foul-smelling drainage from an incision on the upper left arm is admitted with a suspected methicillin-resistant Staphylococcus aureus (MRSA). Which nursing intervention(s) should the nurse include in the plan of care? Select all that apply.

Before leaving the room of a client who is confused, the nurse observes that a half bow knot was used to attach the client's wrist restraints to the movable portion of the client's bed frame. Which action should the nurse take before leaving the room?

A pre-school age child with a congenital heart defect is brought to the clinic by the parent because of a fever and an earache. During the assessment, the parent asks the nurse why the child is at the 5th percentile for weight and height for age. Which response is best for the nurse to provide?

Exhibits Which information from the history and physical, nurses' note, and flow sheet requires further evaluation? Select all that apply.