The nurse reviews the entries in the medical record.

Exhibits

The nurse is ready to begin the blood transfusion. For each potential nursing action, click to specify if the action is indicated or not indicated for the client.

This is because the nurse should assess the client’s level of mobility, strength, and coordination before repositioning them to prevent injury and promote comfort. The nurse should also use appropriate assistive devices, such as a drawsheet, a trapeze bar, or a mechanical lift, to facilitate safe repositioning and reduce the risk of skin breakdown and pressure ulcers.

Choice A is wrong because raising the side rails on both sides of the client’s bed during repositioning can increase the risk of falls and entrapment.

The nurse should only raise the side rail on the opposite side of the bed from where they are working and lower it when they are done.

Choice B is wrong because repositioning the client without assistive devices can cause strain and injury to both the nurse and the client.

The nurse should use assistive devices that are appropriate for the client’s condition and weight.

Choice C is wrong because discussing the client’s preferences for determining a repositioning schedule is not a priority action when preparing to reposition a client who had a stroke.

The nurse should follow the facility’s protocol for repositioning frequency, which is usually every 2 hours, and adjust it according to the client’s needs and comfort.

The nurse should also involve the client in the care plan and respect their preferences whenever possible.

The correct answer is b. “I can visit my nephew who has chickenpox 5 days after the sores have crusted.”

Choice A rationale:

• Statement:“I should take antibiotics when I have a virus.”
• Rationale:This statement is incorrect.Antibiotics are medications that fight bacteria,not viruses.Taking antibiotics when you have a virus will not help you get better and can actually lead to antibiotic resistance.

Choice B rationale:

• Statement:“I can visit my nephew who has chickenpox 5 days after the sores have crusted.”
• Rationale:This statement is correct.Chickenpox is a highly contagious virus that is spread through the air by coughing and sneezing.However,a person with chickenpox is no longer contagious once all of the sores have crusted over.This typically happens about 5 days after the rash first appears.

Choice C rationale:

• Statement:“I should wash my hands for 10 seconds with hot water after working in the garden.”
• Rationale:This statement is partially correct.Handwashing is an important way to prevent the spread of infection.However,the water does not need to be hot.Warm or cold water is just as effective.It is also important to wash your hands for at least 20 seconds,not 10 seconds.

Choice D rationale:

• Statement:“I can clean my cat’s litter box during my pregnancy.”
• Rationale:This statement is incorrect.Cat feces can contain a parasite called Toxoplasma gondii,which can cause a serious infection called toxoplasmosis.Toxoplasmosis can be harmful to a developing baby.It is best to avoid cleaning cat litter boxes during pregnancy.If you must clean the litter box,wear gloves and wash your hands thoroughly afterwards.