While supervising a student who is manually transferring a patient from bed to chair, a nurse intervenes when the student transfers the patient while

Standing close to the patient

Twisting at the torso

Maintaining a wide base of support

Using proper body mechanics

Answer and Explanation

The Correct Answer is B

A.   Standing close to the patient is a recommended practice to maintain proximity and control during patient transfers. This action is appropriate and does not require
intervention.
B.   Twisting at the torso can lead to strain or injury to the nurse's back. It is essential to avoid twisting while performing patient transfers to maintain proper body mechanics and prevent injury.
C.   Maintaining a wide base of support is important for stability and balance during patient transfers. This action is appropriate and promotes safe transfer techniques.
D.   Using proper body mechanics is crucial for preventing injury during patient transfers.

However, the specific concern in this scenario is twisting at the torso, which can lead to strain or injury, rather than overall body mechanics.

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Correct Answer is B

Explanation

The client is at risk for developing pulmonary embolism due to possible deep vein thrombosis. The rationale for this answer is based on the clinical findings noted in the nurse's notes. The presence of a reddened area on the client's calf, along with a difference in calf circumference between the left and right legs,suggests the possibility of deep vein thrombosis (DVT). DVT is a condition where a blood clot forms in a deep vein, typically in the legs. This can lead to a pulmonary embolism if a part of the clot breaks off and travels to the lungs, blocking blood flow. The client's recent long-duration car trip could have contributed to the development of DVT, as prolonged immobility is a known risk factor. The client's high fiber diet and adequate fluid intake are more likely to prevent constipation, and there is no indication of lead exposure, breath sounds issues, or atherosclerosis based on the information provided. Therefore, the most appropriate selections are 'pulmonary embolism' for the condition and 'possible deep vein thrombosis' for the client finding.

A. Maximum assist B. Minimal assist C. Moderate assist D. No assist

Correct Answer is B

Explanation

A. Maximum assist is when the client requires total assistance from one or more persons to perform the activity. In this scenario, the client is able to rise from a seated position
independently with the assistance of a cane, so maximum assist is not appropriate.
B. Minimal assist is when the client requires some assistance or supervision to perform the activity but is able to complete most of the task independently. Since the client can rise from a seated position using a cane for support, they require minimal assistance.
C. Moderate assist is when the client requires more help than minimal assist but can still contribute to the activity. Since the client can perform the task with minimal assistance, moderate assist is not appropriate.
D. No assist is when the client is able to perform the activity without any assistance.
While the client uses a cane for support, they are still able to rise from a seated position independently, so no assist is not appropriate.

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