What is the priority action of the nurse prior to transferring a client from bed to wheelchair

A nurse is assisting a client who has generalized weakness out of the bed to wheelchair which of the following actions should the nurse take?

Lock the wheels of the bed and wheelchair
Rationale the nurse should keep the wheels of the bed and wheelchair in the locked position to prevent them from moving when transferring a client.

A nurse is caring for a client who is rehabilitating from injuries resulting from a motor vehicle crash which of the following client statement to the nurse identify as a priority?

I have not been able to sleep at night because it hurts when I move.
Rationale when using Maslow’s hierarchy of needs the nurse determines at the priority finding is the clients report of pain and difficulty sleeping these are as physiological needs that take priority over higher level needs.

A nurse is caring for an older adult client in a long-term care facility. Which of the following measurement should the nurse take first when assisting with planning the clients care?

Determining the clients mobility
Rationale the greatest risk to the client is injury from moving without assistance if he has impaired mobility therefore the priority action is to collect data about the clients mobility and need for assistance with transferring and ambulating.

A nurse in a long-term care facility find an older adult client lying on the floor next to the bed. Which of the following actions should the nurse take?

Check the client for injuries.
Rationale the client might have sustained a fracture or a head injury. It is the nurses responsibility to check the client for injury after a fall.

A nurse in a long-term care facility find an older adult client lying on the floor next to the bed. Which of the following actions should the nurse take?

Check the client for injuries.
Rationale the client might have sustained a fracture or a head injury it is the nurses responsibility to check the client for injury after a fall.

A nurse at an extended care facility is instructing a class of assistive personnel parentheses a P parentheses about the use of assistive the devices during client ambulation. Which of the following instruction should the nurse include about assisting client to use a cane?

When the client moves he should move the cane forward first.
Rationale when the client moves, he should move the cane forward about 30.5 cm (12 inches)

A nurse is caring for four clients on a surgical unit. Which of the following tears should the nurse delegate to the assistive personnel?

Rationale it is within the APs scope of practice to transfer a stable client who is two days post operative orthopedic surgery.

A nurse is reinforcing teaching with the client about quite walking using the swing through gate. Which of the following statements should the nurse include?

Move both crutches forward, then lift and move your body past the crutches.
Rationale the nurse should instruct the client to use the swing through gate in this matter. Do use this gate, the client must have adequate strength and good coordination.

A nurse is assisting a client who has received crutches in an urgent care center following a foot surgery. Which of the following statements to the nurse identify as an indication that the client needs for the reinforcement of teaching?

I have a set of my brothers crutches in my basement that I can also use.
Rationale the client should not use crutches that belong to someone else. The clients crutches must fit the bodies dimensions, not someone else’s.

A nurse is discharging a client who came to the outpatient clinic with an ankle sprain. Which of the following statements should the nurse identify as an indication that the client understands a discharge instructions?

I’ll apply ice to my ankle for 20 minutes every hour.
Rationale the client should apply ice for 20 minutes every hour for the first 24 to 48 hours

A nurse is preparing a client for ambulation. Which of the following actions should the nurse take to determine the clients level of strength?

Ask the client to push your legs and feet against the nurses palms.
Rationale having the client push her shoulders, arms, fingers, legs, and feet against the resistance of the nurses hands yield concrete, objective data to use for determining the clients level of strength.

A nurse is caring for a client whose hand movement is limited. Which of the following actions should the nurse take to assist the client with feeding?

Providing adequate feeling device for the client.
Rationale adaptive devices such as utensils with vendor angled handles, wide handles, or foam handles, or helpful for clients who hand mobility is limited because these devices promote independence.

A nurse is monitoring a client for complications of mobility. Which of the following findings should the nurse expect?

• Contractors of extremities
• Crackles in the lungs
• Pressure ulcers

Rationale contractures of the extremities is correct contractures of extremities are a complication of immobility because of this use of muscles and joints crackles in the lungs are a complication of a mobility due to pulmonary stasis an accumulation of fluid and mucus the client cannot cough up an exact experience. Pressure ulcers are a complication of a mobility due to increased pressure on bony prominences and all over lack of activity.

A nurse is instructing coworkers about how to minimize lower back pain and avoid repeated episodes of back pain. Which of the following strategy should the nurse include?

Avoid prolong sitting.
Do partial sit ups with the knees bent.
Ask for help when moving clients.
rationale avoid prolong sitting is correct staying in one position for too long even lying down can worsen back pain do partial sit ups with knees bent is correct exercises that strengthen back muscles and help prevent pain include partial sit ups with knees bent knee chest exercises and pelvic tilt‘s ask for help when moving clients is correct the nurse should remind coworkers to use good body mechanics when handling clients and never to attempt lifting or moving clients by themselves.

A nurse at an urgent care center is reinforcing information with a new employee about the difference between sprains and strains. Which of the following are examples of the nurse include as a cause of sprain injury?

Twisting a ligament while walking.
Rationale a sprain is caused by a stretching injury to ligaments around enjoy it. Ligaments being moved or twisted be on their typical range of motion is a potential cars of a sprain.

A nurse is an urgent care center is caring for a client who fell and injured her ankle. The ankle appear swollen and it came up Malik. While the client wait for the x-ray technician, which of the following actions should the nurse take?

Apply ice to the ankle.
Apply a compression bandage. Elevate the foot.
Rationale apply ice to the ankle is correct ice helps reduce swelling in pain apply compression bandage is correct. Wrapping unless elastic bandage around the ankle can help reduce Adema in pain. Elevate the foot is correct. Elevation can help reduce Adema and pain.

A nurse is helping an older adult client ambulate in the hallway for the first time since admission. The client has brought a standard walker from home. To ensure proper use of the walker and the safety of the client, which of the following in action should the nurse take?

Check that the client lives the walker and then places it down in front of her.
Rationale the client should leave the walker in advance it about 15 cm or 6 inches then said it down. This allows the client a wide base of support while she moves forward.

A nurse is Assisting a client with ambulation when the client begins to fall. Which of the following actions should the nurse take?

Lower the client to the floor.
Rationale the nurse should lower the client gently to the floor while supporting your head to prevent injury

A nurse is preparing to help with transferring a client who can partially access to a gurney. Which of the following actions should the nurse take?

Lower the head of the bed.
Rationale the nurse should lower the head of the bed as much as a client can tolerate. If it is safer for the client to move laterally if he is supine.

A nurse is preparing to transfer a client from the bed to a chair. Which of the following actions should the nurse take?

Place a transfer belt on the client.
Rationale a transfer or gait belt help stabilize the client during the chance for and helps keep him from falling.

A nurse is planning care for a client who is a mobile and requires continuous mitten restraints. Which of the following intervention should the nurse contribute to clients care plan?

• Document restraint checks every two hours.
• Educate the clients family about restaurant use.
• Implement passive range of motion exercises.

A nurse is reinforcing teaching with a client who has trained her back muscles while preparing to move to a new apartment. Which of the following instructions to the nurse include?

Bend at the knees when picking up an object.
Rationale bending at the knees help the client maintain her center of gravity then when she lives in the object, she should use her leg muscles, not her back muscles, to lift it.

A nurse is working a night shift and caring for several clients at risk for falls. Which of the following actions should the nurse take?

Instruct the client to use the call light.
Please a fall risk van on each of the clients.

A nurse is preparing to move a client who is only partially able to assist up in bed. Which of the following message with the nurse plan to use?

Two nurses use a friction Dash reducing device.
Rationale: this method reduces the risk of injury to the nurse and to the client. The nurses can use a draw sheet as a friction Dash reducing device.

A nurse is reinforcing teaching about home safety for a client who has a history of falls. Which of the following statements should the nurse identify as an indication that the client understands the instructions?

I will place a bath seat in my shower to use when I bathe.
Rationale a bath he can reduce slipping and falling in the bathtub or shower

A nurse is preparing to transfer a client from lying in bed to sitting in a chair. When identifying the safest method of transfer, which of the following is most important for the nurse to determine?

The clients current weight bearing status.
Rationale the greatest ways to the client is injury from falling during the transfer due to an inability to bear wait. Therefore the priority data for the nurse to collect is to determine how much of the clients wait he can bear. This will help the nurse select the safest method of transfer.

A nurse is assisting with the development of a plan of care for an older adult who is at risk for falls. Which of the following actions should the nurse contribute to the pain?

Keep a night light on in the clients room and bathroom. Like the wheels on bed and wheelchair is during transfers. Place the bedside table within the clients reach.

A nurse is collecting data from a client at a follow up clinic visit for a cute low back pain. A go for this client is to use proper body mechanics at all times. Which of the following findings indicate that the client is meeting this goal?

The client face is the direction of movement when sliding an object across the floor.
Rationale sliding an object across the floor rather than lifting it prevents strain on his lower back muscles. Facing the direction of movement prevents twisting his back.

A nurse is making clients care assignments. Which of the following task to the nearest delegate to assistive personnel?

They the client who had a amputation two days ago.
Assist the client to ambulate using a gait belt.
Feeding a client who had a stroke three months ago.

A nurse is reinforcing teaching about ergonomic principles with a group of assistive personnel. Which of the following strategy should the nurse include in the teaching?

Tighten the abdominal muscles were lifting objects.
Flex knees and hips periodically when standing for a period of time.
In large the distance between the front foot and the back foot one pulling a client towards you.

A nurse in an urgent care clinic is checking a client who was brought in by relative following a motor vehicle crash. The client is not breathing, and the nurses bags of cervical vertible a fracture. Which of the following actions should the nurse take first?

Open the airway using the job address maneuver.
Rationale using the airway, breathing, circulation approach to client care, the first action the nurse should take is to open the clients airway. For a client who is not breathing and might have cervical spine injury, the nurse should use the job thrust maneuver not the head tilt chin lift maneuver and open the airway. The job address maneuver prevents hyperextension of the neck and reduces the risk of further spider injury.

A nurse is preparing to lift a box of supplies in the supply room. Which of the following body mechanics your the nurse plan to use?

Keeping the box close to his body as he lives it.
Rationale proper body mechanics requires keeping the object is close to the body is possible to keep it close to the lifters center of gravity.

Which of the following instructions should a nurse provide to promote the safe use of a cane as an assistive device for a client who is recovering from a musculoskeletal injuries of the lower left extremity?

All the cane on the right side.
Rationale the client should hold a keen on the right uninjured side to provide support for the injure left side.

A nurse is assisting with teaching a class about fall prevention to a group of assisted living residence. Which of the following statements by resident indicates an understanding of the teaching?

It is a good idea to use the handrails in the bathroom.
Rationale handrails or grab bars in the bathroom can help prevent falls. Client should use them for added stability when changing positions.

A nurse is collecting data about a client range of motion. Which of the following instruction to the nurse gave to the client to observe abduction of the shoulder joint?

Raise your arm from your side forward And upward to beside your head.
The shoulder is a ball and socket joint, which the client can flex by moving her arm from her side, forward, and upward to rest by her head.

A nurse is collecting data about a client range of motion. What are the following instructions should the nurse to give to the client to observe the elbow rotate for supination?

Turn each of your hands in for an arm so your palm is facing up.
Rationale the elbow is a hinge joint, which the client can rotate for supination by turning each hand and forearm to have the palm facing up.

A nurse is talking with a client who is beginning a program of moderate exercise. When the nurse reminded client of the importance of doing warm-up exercises, the client ass why. Which of the following reason she’s a nurse give?

Reduce the risk of injury.

Rationale a warm-up. Before exercising helps reduce the possibility of musculoskeletal injuries, such as ligament is strains and muscular strains and prepares a body for the activities ahead. Stretching increase his kinesthetic awareness and reduces the risk of a coordinate movement.

A nurse is planning to go for a passive range of motion for a client who is immobilized. Which of the following actions should the nurse plan to take?

Support extremities above and below joints.
Rationale supporting extremities above and below joints will prevent muscle strain or injury. The nurse can also use the palm of the hand to support choice, or hold extremity’s in forearms.

A nurse is reinforcing teaching with a client who has left and my paresis about how to use a game. Which of the following instruction should the nurse include?

Hold the cane on the right side to provide support for the week her leg.
Rationale the client should hold the cane with the stronger hand, in this case the right hand.

A nurse is caring for a client who is recovering from a stroke. Which of the following information should the nurse include when reinforcing teaching with members of the clients family about reposition the client?

Remove pillows prior to re-positioning.
Elevate the bed to Waze tight. Stand with their feet wide apart.
He’s the direction of movement when we position with a client.

A nurse is caring for a client who has right sided paralysis from a cervical vascular accident. Which of the following intervention should the nurse implement?

Use a footboard to maintain dorsiflexion of the feet.
Rationale a client who has had a stroke with paralysis is at risk for foot drop. The nurse can prevent this by putting the feet in a dorsiflexion position using a firm surface, such as a footboard.

A nurse is collecting data on a clients ability to ambulate with crutches using a 3.8. Which of the following actions should the nurse identify as a risk to the client safety?

The client advances the week or leg first.
Rationale the three-point gate requires the client beer all of the weight on 1 foot. This is not weight-bearing gate. The client should advance and bear weight on both crutches and then advance the unaffected stronger leg. The nurse should be concerned about the safety of the client if Way is being applied to the affected leg.

A nurse is preparing to transfer a client who has limited mobility from the bed to a chair. The client weighs 113.6 kg. (250 lbs) Which of the following actions should the nurse take?

Use a mechanical lift and transfer the client with the assistance of another nurse.
rationale the client should be considered fully dependent. The client has limited mobility and weighs 250 pounds. A caregiver will be required to lift more than 35 pounds of a clients weight. A mechanical lift should be used. In addition, the client should be transferred with an assistant of a minimum of two caregivers. If a client cannot move on to a stretcher independently and weighs less than 200 pounds, a friction reducing device or lateral transfer board should be used in at least two caregivers should assist with the transfer. If the client cannot move independently and weighs more than 90.9 kg or 200 pounds a ceiling lift with a supine sling,

A nurse is reinforcing teaching about I can use with an older adult client who has left-sided weakness. Which of the following instruction should the nurse include?

When walking move your left foot forward first.
Oh the client should move her weaker left foot with the cane first, then bring her stronger leg forward ahead of the cane in the week or foot.

A nurse is collecting data from a client who has required strict bed rest for one week. Which of the following findings should the nurse identify as an indication that the client is ready to ambulate?

Performs active range of motion exercises of all extremities.
Rationale during periods of immobility, it is important to have the client before range of motion exercises to reduce the hazards of immobility. A client who is weak might need a nurse to support her extremities during movement. During active range of motion the client is doing the movement with little or no assistance.

A nurse is performing care for several clients with the help of an assistive personnel. Which task should the nurse asked the AP to perform first?

Take a ABGs basement to the laboratory.
Rationale when using the airway, breathing, circulation approach to client care, the nurse determines that the APs priority task is to take the ABG specimens laboratory because it is essential for determining the clients respiratory status. Processing of the specimen is also urgent because it will deteriorate without placing it on ice and transporting it immediately.

An older adult client falls and fractured her hip well and nurses assisting her to the bathroom. A client sues the nurse for negligence. The nurse should identify which of the following principles as a standard that will legally determine her liability for the client injury?

Another staff nurse describes how a reasonably prudent yours would have perform under the same circumstances.
Rationale in court, the standard that determines negligence is how a reasonably prudent nurse with the same education and experience would have performed under the same circumstances.

A nurse delegates the application of wrist restraints for a client who is confused to an assistive personnel. The AP padded the rest is just restraints and secure the straps to the bedframe with a double knot. Which of the following actions should the nurse take?

Re-Tyler is straight straps with a slip knot.
Rational a double not prevent easy release in the event of an emergency. Slipknots and Happel nuts are types of not that allow quick release.

A nurse is caring for a client when the safety on the bed plugs electrical outlet pops and begins to smoke. Which of the following actions is a nurse is priority?

Move any clients in immediate vicinity.
Rationale the greatest risk to the client is injury from a smoke and fire therefore the nurses first action is to move any clients near the smoke to a safe location. The acronym race is a reminder of the order in which to take steps in the event of a fire. The nurse should rescue the clients, activate the fire alarm, couldn’t find the fire, and extinguish the fire.

A nurse inches of clients room to answer the call light and sees the client is in the bathroom on the floor. Which of the following actions should the nurse take first?

Obtain the clients vital signs.
Rationale the first action the nurse should take when using the nursing process is to collect data from the client. I am updating and review the clients vital signs the nurse can take the necessary precautions to prevent further injury to the client.

A nurse is caring for a client who is confused and has pulled out of his peripheral IV catheter three times. Which of the following actions should the nurse consider?

Please mid restraints on the clients hands.
Rationale with me and restaurants in place, the client would not be able to pull out that his catheter. However restraints, both physical and chemical, our last resort. If the nurse exhaust other possibilities, such as having family member stay with a client, she should reset request that the provider describe had restaurants.

What should the nurse do prior to transferring the client out of bed to a chair?

What action should the nurse take when transferring a client from bed to wheelchair?

When assisting a patient into a wheelchair What action would the nurse take to ensure the patient is properly positioned before sitting down in the wheelchair?

When assisting a client from the bed into a wheelchair the nurse assesses the client for signs of dizziness?