A nurse is preparing to transfer a client who can bear weight on one leg from the bed to a chair. After securing a safe environment, which of the following actions should the nurse take next?

Correct Answer: A

Rationale: The correct next action for the nurse to take is to check for orthostatic hypotension. This step is crucial as it ensures the client's safety during the transfer process. Orthostatic hypotension is a drop in blood pressure that can occur when a person moves from a lying down position to a sitting or standing position. By checking for orthostatic hypotension before transferring the client, the nurse can prevent potential complications such as dizziness, lightheadedness, or falls. Choices B, C, and D are incorrect in this scenario as they do not address the immediate safety concern of assessing for orthostatic hypotension.

Correct Answer: C

Rationale: The correct answer is C) "I will take the medication until my sore throat goes away." This statement indicates understanding because it shows the client knows the importance of completing the full course of antibiotics to effectively treat the infection and prevent antibiotic resistance. Option A is incorrect because doubling the dose of medication if a dose is missed can lead to overdose and harmful side effects. Option B is incorrect because amoxicillin clavulanate is typically recommended to be taken with food to minimize gastrointestinal side effects, not on an empty stomach. Option D is incorrect because stopping the medication if itching occurs may result in inadequate treatment of the infection. Itching alone is not necessarily a sign to discontinue the medication. In an educational context, it is crucial to emphasize the importance of completing the full course of antibiotics as prescribed by the healthcare provider to ensure the infection is fully treated and to prevent the development of antibiotic-resistant bacteria. Patients should be educated on proper medication administration, including timing with meals, and the importance of reporting any concerning side effects to their healthcare provider.

Correct Answer: A

Rationale: The correct action for the nurse to take is to check the stockings for wrinkles. This is important to ensure that the stockings are applied correctly without any folds or wrinkles, which can hinder proper circulation and compression. Option B is incorrect because compression stockings should be applied with the client lying down, not sitting in a chair. Option C is unnecessary as the size of the client's foot is unlikely to change postoperatively. Option D is incorrect as compression stockings are usually worn continuously except for specific care needs.

Correct Answer: D

Rationale: A low WBC count (3,300/mm3) is a contraindication to clozapine because this medication can cause severe neutropenia. Neutropenia is a significant reduction in white blood cell count, increasing the risk of infections. Elevated fasting blood glucose, asthma, and hypertension are not direct contraindications to clozapine.

Correct Answer: D

Rationale: Offering the client 240 ml (8 oz) of oral fluids every 4 hours is essential to maintain hydration in a client with dehydration who is receiving continuous IV infusion. This intervention helps ensure an adequate fluid balance. Monitoring the client's intake and output every 6 hours is necessary to assess hydration status and response to treatment. Administering furosemide to the client, choice B, is contraindicated in dehydration as it can further deplete fluid volume. Checking the IV infusion every 8 hours, as in choice C, is important but not as critical as ensuring oral fluid intake to promote hydration.