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A safety measure to implement when transferring a client with hemiparesis from a bed to a wheelchair is:
- A. standing the client and walking him or her to the wheelchair.
- B. moving the wheelchair close to client's bed and standing and pivoting the client on his unaffected extremity to the wheelchair.
- C. moving the wheelchair close to client's bed and standing and pivoting the client on his affected extremity to the wheelchair.
- D. having the client stand and push his body to the wheelchair.
Correct Answer: B
Rationale: Moving the wheelchair close to client's bed and having him stand and pivot on his unaffected extremity to the wheelchair is safer because it provides support with the unaffected limb.
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The postoperative male client has been unable to urinate into the urinal while lying in bed. Which interventions are appropriate to promote voiding for this client who is to be discharged home within a few hours? Select all that apply.
- A. Have the client apply an external condom catheter while lying flat in bed
- B. Assist the client to stand at the bedside to attempt to urinate in a urinal.
- C. Administer a prescribed analgesic if the client is experiencing pain.
- D. Turn on running water so it is heard while the client attempts to void.
- E. Ask the client to imagine being at home and voiding in his own bathroom.
Correct Answer: B,C,D,E
Rationale: B: Standing mimics normal voiding position. C: Pain relief aids relaxation for voiding. D: Running water stimulates the voiding reflex. E: Guided imagery promotes relaxation. A: Condom catheters manage incontinence, not promote voiding.
The nurse is observing the UAP prepare a shower for the client who requires assistance with ambulation and hygiene. Which action(s) by the UAP indicate understanding of the procedure? Select all that apply.
- A. Sets the water temperature at 100° to 105° F (37° to 40° C).
- B. Locks the door to provide the client with privacy.
- C. Uses a chair for the client to sit on in the shower.
- D. Ensures a nonskid surface is in the shower.
- E. Helps to wash areas the client cannot reach.
Correct Answer: C,D,E
Rationale: C: A shower chair prevents falls for a client with ambulation issues. D: A nonskid surface enhances safety. E: Assisting with hard-to-reach areas supports hygiene. A: Water should be 110°-115°F for comfort. B: Locking the door is unsafe for a client needing assistance.
A client with dysphagia is ready to eat lunch. Which of these foods on the tray would be best to start with when assisting the client?
- A. diced fruit
- B. apple juice with a liquid thickener
- C. Jell-O™
- D. toast
Correct Answer: B
Rationale: A client with dysphagia is at risk for aspiration. A liquid thickener will allow the LPN to assess the client's ability to swallow prior to introducing pureed or solid foods. Since Jell-O™ melts into a clear liquid, it should not be used when assessing swallowing ability.
Pulling is easier than pushing. So pulling a client rather than pushing him or her has which of the following advantages?
- A. Reduces workload
- B. Decreases opposition from gravity
- C. Maintains stability
- D. Prevents muscle strain
Correct Answer: A
Rationale: Pulling reduces workload by working with gravity, lowering the effort needed compared to pushing against it.
Following a classic cholecystectomy resection for multiple stones, the PACU nurse observes a serosanguious drainage on the dressing. The most appropriate intervention is to:
- A. notify the physician of the drainage.
- B. change the dressing.
- C. reinforce the dressing.
- D. apply an abdominal binder.
Correct Answer: C
Rationale: Serosanguious drainage is expected at this time. The dressing should be reinforced. Changing a new postop dressing increases the risk of infection. An abdominal binder interferes with visualization of the dressing.