Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
A nurse is caring for a client who is sitting in a chair and asks to return to bed.
Which of the following actions is the nurse's priority?
A. Obtain a walker for the client to use to transfer back to bed.
While obtaining a walker might be helpful, it's not the first step. The nurse needs to assess the client's ability to assist with the transfer before deciding on the most appropriate aid.
B. Call for additional staff to assist with the transfer.
Calling for additional staff may be necessary, but this should come after assessing the client's ability to help with the transfer.
C. Use a transfer belt and assist the client back into bed.
Using a transfer belt is a good practice for safe transfers, but again, the nurse must first determine if the client can assist. This ensures the appropriate use of resources and techniques.
D. Determine the client's ability to help with the transfer.
Assessing the client's ability to help with the transfer is the first step. This assessment will guide the nurse in choosing the safest and most appropriate method for transferring the client, considering their capabilities and safety.
This question is an excerpt from Nurse Dive's nursing test bank - Nursing Fundamentals Exam 3. Take the full exam now
Full Explanation
The correct answer is D. Determine the client's ability to help with the transfer.
Choice A rationale:
While obtaining a walker might be helpful, it's not the first step. The nurse needs to assess the client's ability to assist with the transfer before deciding on the most appropriate aid.
Choice B rationale:
Calling for additional staff may be necessary, but this should come after assessing the client's ability to help with the transfer.
Choice C rationale:
Using a transfer belt is a good practice for safe transfers, but again, the nurse must first determine if the client can assist. This ensures the appropriate use of resources and techniques.
Choice D rationale:
Assessing the client's ability to help with the transfer is the first step. This assessment will guide the nurse in choosing the safest and most appropriate method for transferring the client, considering their capabilities and safety.
Similar Questions
A nurse is preparing to conduct a fall risk screening on a client.
Which of the following variables will the nurse use to evaluate the client? (Select all that apply.)
A. Fall history.
Maintaining the patency of the client's airway is the priority action. During a seizure, the client may lose consciousness and have difficulty breathing. Ensuring a clear airway is essential to prevent hypoxia and maintain oxygenation. This can be achieved by positioning the client on her side and removing any obstructions from her mouth to allow for adequate airflow.
B. Medical diagnosis.
Identifying the poison the client ingested is important for providing appropriate medical treatment, but it is not the priority action in this scenario. Airway management takes precedence because it addresses the immediate threat to the client's life.
C. Use of assistive devices.
Measuring the client's blood pressure is a necessary assessment, but it is not the priority during an active seizure. Airway management and seizure control are the immediate concerns. Once the seizure is controlled and the airway is secured, other assessments, including blood pressure measurement, can be performed.
D. Mental status.
Positioning the client on her side is a correct action, but it should be done after ensuring the patency of the airway. Placing the client on her side helps prevent aspiration in case of vomiting during or after the seizure. However, it is not the priority over ensuring the client can breathe properly.
E. Do-not-resuscitate status.
Full Explanation
Choice A rationale:
Maintaining the patency of the client's airway is the priority action. During a seizure, the client may lose consciousness and have difficulty breathing. Ensuring a clear airway is essential to prevent hypoxia and maintain oxygenation. This can be achieved by positioning the client on her side and removing any obstructions from her mouth to allow for adequate airflow.
Choice B rationale:
Identifying the poison the client ingested is important for providing appropriate medical treatment, but it is not the priority action in this scenario. Airway management takes precedence because it addresses the immediate threat to the client's life.
Choice C rationale:
Measuring the client's blood pressure is a necessary assessment, but it is not the priority during an active seizure. Airway management and seizure control are the immediate concerns. Once the seizure is controlled and the airway is secured, other assessments, including blood pressure measurement, can be performed.
Choice D rationale:
Positioning the client on her side is a correct action, but it should be done after ensuring the patency of the airway. Placing the client on her side helps prevent aspiration in case of vomiting during or after the seizure. However, it is not the priority over ensuring the client can breathe properly.
How often must you or an assistant check on a patient who is restrained?
A. Every 45 minutes.
Family members who smoke must be at least 10 ft from the client when oxygen is in use. Oxygen supports combustion, and smoking near an oxygen source can lead to a fire. Keeping family members who smoke at a safe distance minimizes this risk.
B. Every 30 minutes.
Nail polish remover or hair spray should not be used near a client who is receiving oxygen. These substances contain flammable ingredients, which can ignite in the presence of oxygen. Instructing the client and those around them to avoid using such products prevents potential accidents.
C. Every hour.
A "No Smoking" sign should be placed on the front door. This serves as a visual reminder to visitors and family members that smoking is prohibited in the vicinity, reducing the risk of fire when oxygen is in use. Clear communication through signage is essential in maintaining a safe environment.
D. Every 2 hours.
Cotton bedding and clothing should be replaced with items made from wool. This statement is incorrect. There is no specific requirement to replace cotton items with wool for a client using oxygen. Instead, the focus should be on fire safety measures and ensuring that flammable materials are kept away from the oxygen source.
Full Explanation
Choice A rationale:
Family members who smoke must be at least 10 ft from the client when oxygen is in use. Oxygen supports combustion, and smoking near an oxygen source can lead to a fire. Keeping family members who smoke at a safe distance minimizes this risk.
Choice B rationale:
Nail polish remover or hair spray should not be used near a client who is receiving oxygen. These substances contain flammable ingredients, which can ignite in the presence of oxygen. Instructing the client and those around them to avoid using such products prevents potential accidents.
Choice C rationale:
A "No Smoking" sign should be placed on the front door. This serves as a visual reminder to visitors and family members that smoking is prohibited in the vicinity, reducing the risk of fire when oxygen is in use. Clear communication through signage is essential in maintaining a safe environment.
Choice E rationale:
A fire extinguisher should be readily available in the home. Despite precautions, accidents can still happen. Having a fire extinguisher nearby allows for immediate response in case of a fire-related emergency, ensuring the safety of the client and those around them.
Choice D rationale:
Cotton bedding and clothing should be replaced with items made from wool. This statement is incorrect. There is no specific requirement to replace cotton items with wool for a client using oxygen. Instead, the focus should be on fire safety measures and ensuring that flammable materials are kept away from the oxygen source.
Proper hand-washing technique requires that a nurse wash for a minimum of what length of time?
A. 30 seconds.
While 30 seconds of hand-washing can be very effective, the minimum recommended time is typically 20 seconds.
B. 10 seconds.
Washing hands for 10 seconds is generally not sufficient to effectively remove germs and bacteria.
C. 45 seconds.
Washing hands for 45 seconds is highly effective, but it is more than the minimum required time.
D. 20 seconds.
The Centers for Disease Control and Prevention (CDC) recommend washing hands for at least 20 seconds to ensure proper cleaning and removal of harmful pathogens. This duration is considered sufficient to cover all parts of the hands thoroughly.
Full Explanation
Choice B rationale:
Call for additional staff to assist with the transfer. The nurse's priority in this situation is ensuring the safety of the client during the transfer from the chair to the bed. Calling for additional staff provides the necessary support to safely move the client, minimizing the risk of falls or injuries. It is crucial to have an adequate number of staff members to assist in transfers, especially when the client's mobility is compromised.
Choice A rationale:
Obtain a walker for the client to use to transfer back to bed. While a walker can be helpful for mobility, the client has already asked to return to bed, indicating the immediate need for assistance. Waiting to obtain a walker could delay the transfer, potentially putting the client at risk.
Choice C rationale:
Use a transfer belt and assist the client back into bed. Using a transfer belt is a suitable technique for assisting clients with mobility. However, the nurse's priority in this scenario is to ensure there is enough staff assistance to guarantee a safe transfer. The nurse should not attempt to perform the transfer alone, even with a transfer belt, as it might be unsafe for both the nurse and the client.
Choice D rationale:
Determine the client's ability to help with the transfer. While assessing the client's ability to participate in the transfer is important, it is not the nurse's priority in this situation. The immediate concern is to secure adequate assistance to safely move the client back to bed.