the uaps working on a chronic neuro unit ask the lpnlvn to help them determine the safest way to transfer an elderly client with left sided weakness f
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Fundamentals of Nursing HESI

1. The UAPs working on a chronic neuro unit ask the LPN/LVN to help them determine the safest way to transfer an elderly client with left-sided weakness from the bed to the chair. What method describes the correct transfer procedure for this client?

Correct answer: D

Rationale: The correct method for transferring an elderly client with left-sided weakness from the bed to the chair involves moving the chair parallel to the right side of the bed and standing the client on the right foot. This technique provides a stable and safe transfer by utilizing the stronger side of the client to support the transfer. Choices A, B, and C are incorrect because placing the chair at a right angle to the bed on the client's left side, assisting the client to a standing position and placing the right hand on the armrest, and having the client pivot to the left before sitting do not address the client's left-sided weakness and may increase the risk of falls or injuries.

2. During a complete bed bath for a client, after removing the gown and placing a bath blanket over the body, which of the following areas should the nurse wash first?

Correct answer: A

Rationale: When performing a complete bed bath, it is essential to wash the face first. Washing the face initially helps to maintain the client's privacy and comfort. Additionally, starting with the face prevents re-contamination of already cleaned areas. Washing the feet first (Choice B) is not ideal as it can lead to potential contamination of the upper body parts. Starting with the chest (Choice C) or arms (Choice D) is not recommended due to the risk of water dripping onto the client's face, causing discomfort and compromising privacy.

3. A client with a history of hypertension is prescribed a diuretic. Which of the following laboratory values should the nurse monitor to evaluate the effectiveness of the medication?

Correct answer: B

Rationale: The correct answer is to monitor serum potassium levels. When a client is prescribed a diuretic, monitoring serum potassium levels is essential to evaluate the medication's effectiveness and to detect potential electrolyte imbalances. Diuretics can cause potassium loss, leading to hypokalemia, which can have serious consequences such as cardiac arrhythmias. Monitoring serum calcium levels (Choice A) is not typically required when assessing the effectiveness of diuretics. Similarly, monitoring serum sodium levels (Choice C) is important for other conditions but is not the primary concern when evaluating diuretic therapy. Monitoring serum magnesium levels (Choice D) is also important, but potassium levels are more critical in assessing diuretic effectiveness and preventing complications.

4. During a patient assessment, which principle should be a priority?

Correct answer: D

Rationale: During a patient assessment, critical thinking is a priority because a patient's condition can change rapidly, necessitating continuous critical thinking and adaptation of nursing interventions. While foot care, daily bathing, and hygiene needs are important components of patient care, they may not always take precedence over critical thinking, which guides the nurse in making timely and appropriate decisions based on the patient's current condition and needs. Therefore, critical thinking stands out as the most crucial principle during patient assessments.

5. During an admission assessment, a healthcare professional finds a client's radial pulse rate to be 68/min and the simultaneous apical pulse to be 84/min. What is the client’s pulse deficit (per minute)?

Correct answer: A

Rationale: The pulse deficit is calculated by finding the difference between the apical and radial pulse rates. In this case, the difference is 84 - 68 = 16. This indicates that there is a pulse deficit of 16 beats per minute. Choices B, C, and D are incorrect as they do not accurately reflect the difference between the two pulse rates.

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