Nokea
A client with right-sided weakness becomes dizzy, loses balance, and begins to fall while the nurse is assisting with ambulation. Which nursing actions would best prevent injury to the client and nurse while guiding the client to a horizontal position on the floor?
- A. Step behind client with arms around waist, squat using the quadriceps, and lower client to the floor
- B. Step in front of client, brace knees and feet against the client's, and assist to the floor gently
- C. Step slightly behind client with feet apart, extend one leg, and let client slide against it to the floor
- D. Step 12 inches behind the client, support under axillae, tighten back, and lower client to the floor
Correct Answer: C
Rationale: This technique (C) ensures the nurse maintains balance with feet apart and uses their leg to guide the client safely to the floor, minimizing injury risk to both. Option A risks the nurse losing balance, B places the nurse in an unsafe position, and D involves improper body mechanics.
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The nurse is preparing to administer an anticholinergic medication to a client with irritable bowel syndrome. Which of the following findings would require follow-up prior to administering the medication?
- A. bladder scan that shows 650 mL of urine after voiding
- B. history of age-related macular degeneration
- C. frequent loose stools in the past 24 hours
- D. reports of fatigue and drowsiness
Correct Answer: A
Rationale: Anticholinergics can worsen urinary retention, so 650 mL post-void residual (A) requires follow-up. Macular degeneration (B), loose stools (C), and fatigue (D) are not contraindications.
An adult is admitted to the long-term care facility. She had a cerebrovascular accident and no longer needs acute care. The client has left side hemiplegia. Because of the type of deficit the client has, the nurse knows that this woman is at increased risk for which of the following?
- A. Speech and language deficits
- B. Slow and cautious behavior
- C. Difficulty with visual-spatial relationships
- D. Hearing deficits
Correct Answer: C
Rationale: Left hemiplegia from a right brain CVA increases risk for visual-spatial deficits, as the right hemisphere processes spatial awareness, unlike speech (left hemisphere), behavior, or hearing.
The nurse is caring for a client who is recovering from a cerebrovascular accident and is partially paralyzed on the right side. How should the nurse position the chair when getting the client out of bed?
- A. On the right side of the bed facing the foot of the bed
- B. On the right side of the bed facing the head of the bed
- C. On the left side of the bed facing the foot of the bed
- D. On the left side of the bed facing the head of the bed
Correct Answer: C
Rationale: Placing the chair on the left (unaffected) side facing the foot allows the client to pivot using their stronger side, facilitating safe transfer. Right-side placement or incorrect orientation hinders mobility.
The nurse inserts a small bore nasogastric (NG) tube and prepares to initiate enteral feedings for a hospitalized client with laryngeal cancer. Which action should the nurse take first?
- A. Crush and administer medications
- B. Dilute enteral formula as prescribed
- C. Flush the tube with 30 mL of water
- D. Verify tube placement with an x-ray
Correct Answer: D
Rationale: Verifying NG tube placement with an x-ray (D) is the first step to ensure safety before feedings or medications. Other actions follow confirmation.
The nurse is caring for a client who was recently prescribed methadone for chronic, severe back pain. The client indicates taking extra tablets in the last 6 hours when the pain recurred. Which findings during discharge require the client to be monitored longer in the hospital setting? Select all that apply.
- A. Falls asleep when the nurse is talking
- B. Frequently scratches from pruritus
- C. Has third emesis since taking medication
- D. Monitor shows occasional premature ventricular contractions
- E. Pulse oximetry reading is 92%
Correct Answer: A,C,D
Rationale: Falling asleep (A), vomiting (C), and premature ventricular contractions (D) indicate possible methadone overdose or toxicity, requiring extended monitoring. Pruritus (B) is a common side effect, and 92% oxygen saturation (E) is not critical.