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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 client's height

The client's ability to communicate

The client's current weight-bearing status

The type of equipment used in previous transfers

Answer and Explanation

The Correct Answer is C

A. Knowing the client's height can be helpful for ergonomic considerations, but it is not critical for the transfer process.

B. The client's ability to communicate is important for understanding their needs and preferences but does not directly impact the physical safety of the transfer.

C. The client's current weight-bearing status is crucial to determine the safest method of transfer. If the client cannot bear weight, additional assistance or equipment may be necessary to prevent falls or injury.

D. While knowing the type of equipment used in previous transfers can provide insight, it is secondary to understanding the client's current physical capabilities and needs.

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A. Kussmaul respirations B. Apneustic respirations C. Stridor D. Cheyne-Stokes respirations

Correct Answer is D

Explanation

A. Kussmaul respirations are characterized by deep, rapid breathing typically associated with metabolic acidosis, not alternating periods of hyperventilation and apnea.

B. Apneustic respirations involve prolonged inspiration and shorter expiration phases, usually seen in brain injuries, but do not reflect alternating hyperventilation and apnea.

C. Stridor is a high-pitched wheezing sound indicative of upper airway obstruction, which does not describe the breathing pattern in this scenario.

D. Cheyne-Stokes respirations are defined by alternating periods of deep, rapid breathing (hyperventilation) followed by periods of no breathing (apnea), making this the correct choice for the client’s described pattern.

A. Mix the three medications together prior to administering. B. Flush the NG feeding tube with 30 mL of water immediately following medication administration. C. Dilute each medication with 10 mL of tap water. D. Maintain the head of the bed in a flat position for 30 min following medication administration.

Correct Answer is B

Explanation

A. Mixing medications can alter their effectiveness and increase the risk of tube blockage. Each medication should be administered separately.

B. Flushing the NG tube with 30 mL of water after administering medications is important to ensure that the medications are cleared from the tube and absorbed properly by the patient. This also helps to prevent tube occlusion.

C. Diluting medications may not be necessary for all liquid medications, and it depends on the specific medication's guidelines. Each medication should be administered as directed.

D. The head of the bed should be elevated during and after medication administration to prevent aspiration. Keeping it flat is not recommended.

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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?

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Correct Answer is D

Explanation

Correct Answer is B

Explanation

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Take full exam for free 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?

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Explanation

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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?