The practical nurse (PN) is preparing to transfer an unresponsive client from the bed to a stretcher. Which client data is most important for the PN to obtain before beginning the transfer?
Skin turgor.
Body weight.
Temperature.
Blood pressure.
The Correct Answer is D
A. Skin turgor is important for assessing hydration status, but it is not the most critical factor when preparing for a safe transfer. For an unresponsive client, ensuring stable hemodynamic conditions is more urgent. Blood pressure provides essential information about the client’s circulatory status, which is crucial for assessing the risks associated with the transfer.
B. Body weight is generally used for dosing medications or assessing nutritional status and is not immediately relevant for ensuring a safe transfer of an unresponsive client. Although body weight might be useful in planning the transfer logistics, it does not impact immediate safety concerns.
C. Temperature can indicate infection or other issues but does not directly affect the immediate safety of the transfer process. While monitoring temperature is part of overall care, it is not the most pressing concern during the transfer.
D. Blood pressure is essential to check before the transfer because it reflects the client’s cardiovascular stability. Low or unstable blood pressure might increase the risk of complications during the transfer, such as a sudden drop in blood pressure that could lead to a fall or injury.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Isoniazid can cause side effects like peripheral neuropathy, but ringing in the ears is not a common symptom of this medication.
B. Gentamicin can cause ototoxicity, which includes symptoms such as ringing in the ears (tinnitus). This side effect is significant and should be reported to the healthcare provider for further evaluation.
C. Pyridoxine is used to prevent neuropathy caused by isoniazid and does not cause ringing in the ears.
D. Rifampin is an antitubercular medication but is not commonly associated with tinnitus as a side effect. The immediate concern with ringing in the ears is related to gentamicin.
Correct Answer is ["G","H"]
Explanation
A. 50% dextrose
50% dextrose is not isotonic; it is a hypertonic solution. Hypertonic solutions have a higher concentration of solutes compared to the cells, causing water to move out of the cells and into the extracellular space, which does not treat fluid volume deficit effectively.
B. 0.45% sodium chloride
0.45% sodium chloride, also known as half-normal saline, is a hypotonic solution. Hypotonic solutions have a lower concentration of solutes compared to the cells, which would cause water to move into the cells rather than stay in the extracellular space to address fluid volume deficit.
C. 20% dextrose
20% dextrose is a hypertonic solution. It contains a higher concentration of dextrose compared to the extracellular fluid, which draws water into the extracellular space but is not used for treating fluid volume deficits.
D. 5% dextrose
5% dextrose (D5W) is initially isotonic but becomes hypotonic once metabolized, as the dextrose is used up and only water remains. It is not suitable for continuous isotonic fluid therapy for fluid volume deficit.
E. 5% dextrose with 0.45% sodium chloride
5% dextrose with 0.45% sodium chloride is a hypertonic solution. While it starts isotonic, it becomes hypotonic once the dextrose is metabolized, making it unsuitable for long-term isotonic fluid replacement.
F. 5% dextrose with lactated Ringer's
5% dextrose with lactated Ringer's is a hypertonic solution. It contains both dextrose and electrolytes, which are not purely isotonic and may not be ideal for addressing fluid volume deficits on their own.
G. Lactated Ringer's
Lactated Ringer's is an isotonic solution. It has a similar osmolarity to plasma and is used for fluid volume replacement, helping to restore blood volume and maintain electrolyte balance.
H. 0.9% sodium chloride
0.9% sodium chloride, or normal saline, is an isotonic solution. It has the same osmolarity as plasma and is commonly used for fluid volume replacement and maintaining hydration
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