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A newly admitted patient with a diagnosis of right-sided weakness resulting from cerebrovascular attack puts on her light and asks for assistance to the bathroom. You have not yet assessed this patient's transfer abilities. What will you do?
- A. Ask the certified nursing assistant (CNA) assigned to the patient to carefully assist her to the bedside commode.
- B. Tell the CNA that the patient has right-sided weakness but can transfer with minimal assistance.
- C. Ask the CNA to accompany you and together transfer the patient to the bedside commode.
- D. Ask the CNA to assist the patient with a bed pan until you have time to get an order for a lift for her.
Correct Answer: C
Rationale: Assessing transfer abilities with assistance ensures safety, as the patient's capabilities are unknown.
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Describe the actions you will take after you assist Mr. Weldon back to bed.
- A. Assess the skin tear and clean it with saline.
- B. Apply a sterile dressing to the skin tear.
- C. Notify the physician of the incident.
- D. Document the incident and vital signs.
Correct Answer: A,B,C,D
Rationale: These actions address the injury, prevent infection, ensure communication, and meet documentation requirements.
How can you be certain that the wheels of a stretcher are locked before transferring a patient?
- A. Press the foot lock and announce loudly that the wheels are locked.
- B. Physically attempt to move the stretcher, even if you have locked the wheels.
- C. Bend down on one knee to ensure that the red lever is up and the green one is down.
- D. Assign one person to hold the stretcher in place while the patient is transferred.
Correct Answer: B
Rationale: Physically attempting to move the stretcher confirms that the wheels are locked, ensuring safety during patient transfer.
You are caring for a patient on the first day after surgery. You have orders to get her up in the chair for 30 minutes twice a day. Her BP is 110/64 and P 86 while lying down. After you assist her to dangle, her BP is 102/60 and P 102. What will you do?
- A. Return her to lying position and monitor vitals
- B. Proceed to transfer her to the chair
- C. Administer IV fluids immediately
- D. Notify the physician
Correct Answer: A
Rationale: A drop in BP and increased pulse suggest orthostatic hypotension; returning her to bed and monitoring is safest.
Which assistive device will you use to assist a patient with mild right-sided weakness as he moves from the bed to the wheelchair?
- A. Transfer belt
- B. Slide sheet
- C. Slide board
- D. Transfer board
Correct Answer: A
Rationale: A transfer belt provides support and safety for a patient with mild weakness during transfers.
Why is it important to explain what you will be doing when you assist a patient with position changes?
- A. The patient may be sedated or have an impaired level of consciousness.
- B. The patient may have a preference about who performs repositioning.
- C. The patient will be more cooperative with the position change.
- D. The patient will be less likely to resist during the position change.
- E. The patient can more easily assist with the position change.
Correct Answer: C,D,E
Rationale: Explaining procedures promotes cooperation, reduces resistance, and enables patient assistance, enhancing safety and comfort.