Question

68.a nurse is preparing to transfer a client from lying in bed to sitting in a chair. when identifying the safest method of transfer, which of the following is most important for the nurse to determine?
a. the clients ability to communicate
b. the clients current weight - bearing status
c. the clients activity tolerance
d. the type of equipment the staff used to transfer the client in the past
69.a nurse is collecting data from a client who has a wrist restraint in place. which of the following findings should the nurse identify as an indication of a complication of the restraint?
a. the client has a capillary refill of 1 second.
b. the client has full range of motion in her wrist.
c. the client is attempting to remove the restraint.
d. the clients hand is cool and pale.
70.a nurse is preparing a sterile field. which of the following actions should the nurse identify as contaminating the field?
a. placing a sterile dressing 5 cm (2 in) from the border of the sterile field
b. holding a sterile item at just above waist level
c. opening a sterile package directly over the middle of the sterile field
d. opening the sterile tray by first unfolding the flap furthest from his body
71.a nurse is planning care for a client who has anorexia and has manifestations of malnutrition. when reviewing the clients laboratory values, which of the following test results should the nurse expect to be low?
a. d - dimer
b. troponin
c. creatinine
d. albumin

Explanation:

• Question 68: When transferring a client from bed to chair, the client's current weight - bearing status is crucial as it directly affects the physical ability to perform the transfer safely. Communication ability (A) is important but not the most critical for the physical transfer method. Activity tolerance (C) is more related to how long an activity can be sustained rather than the method of transfer. Past equipment use (D) may not be relevant to the current situation.
• Question 69: A cool and pale hand (D) indicates poor circulation, which is a complication of a wrist restraint. A capillary refill of 1 second (A) is normal. Full range of motion (B) is a positive sign. Attempting to remove the restraint (C) is a behavioral response, not a complication sign.
• Question 70: Opening a sterile package directly over the middle of the sterile field (C) can cause contamination from above. Placing a sterile dressing 5 cm (2 in) from the border (A) is within the acceptable non - sterile border. Holding a sterile item at just above waist level (B) is correct. Opening the sterile tray by first unfolding the flap furthest from the body (D) is the proper technique.
• Question 71: Albumin (D) is a protein synthesized in the liver. In malnutrition (such as in anorexia), there is not enough protein intake, so albumin levels are low. D - dimer (A) is related to clotting. Troponin (B) is related to heart muscle damage. Creatinine (C) is related to kidney function.

Answer:

• 68. B. The client's current weight - bearing status
• 69. D. The client's hand is cool and pale.
• 70. C. Opening a sterile package directly over the middle of the sterile field
• 71. D. Albumin