Exam 2024 Update
A nurse is preparing to transfer a client who has left-sided weakness from the bed
to a chair. Which of the following actions by the nurse demonstrates correct
transfer technique?
A. Positioning the chair slightly behind the nurse so that the seat faces the client's
bed
B. Placing the client's left leg in front of the right leg just prior to the transfer
C. Aligning the nurse's knees with the client's knees just before the transfer
D. Grasping the client under the axillae to assist them to their feet -
✔✔✔ANSWER-C. Aligning the nurse's knees with the client's knees just before
the transfer.
Rationale: This is a correct strategy that helps the nurse safely stabilize the client
while moving to a standing position.
, A nurse in an emergency department is providing discharge teaching to a client
who has a knee injury and will be using a pair of axillary crutches for the first time.
Which of the following instructions should the nurse include?
A. "Lean on the crutches to support your body weight when standing."
B. "Fully extend your arms when holding onto the hand grips."
C. "Hold the crutches on your unaffected side when preparing to sit in a chair."
D. "Hold the crutches 9 inches in front of and to the side of each foot." -
✔✔✔ANSWER-C. "Hold the crutches on your unaffected side when preparing to
sit in a chair."
Rationale: The crutches should be held on the unaffected side when preparing to sit
in a chair.
Incorrect rationale:
- crutches should be fitted so the client's arms are flexed ~ 30° at elbows when
holding onto hand grips.
- crutches should be held 6 inches in front of & to side of each foot to assist w/
balance
A nurse is assisting with the ambulation of a client who becomes light-headed and
begins to fall. Which of the following actions should the nurse take?
A. Wrap both arms around the client's arms and shoulders.
B. Move both feet together when the client begins to fall.
C. Protect the client's extremities while lowering them to the floor.