What should a nurse do before assisting a patient to stand up from the bed?

Correct Answer: C

Rationale: Assessing the patient's readiness and strength before assisting them to stand prevents falls and injuries by ensuring they're physically capable of the transition. This involves checking their stability, pain level, and muscle strength, tailoring assistance accordingly. Telling them to stand alone risks harm if they're weak or dizzy. Pulling them abruptly ignores their condition and could cause strain or falls. Starting ambulation exercises immediately skips this critical safety step. Nurses prioritize patient safety assessment identifies risks like orthostatic hypotension or post-surgical weakness, ensuring a smooth, supported move that protects both patient and caregiver.

Correct Answer: C

Rationale: Securing a restraint to the bed's side rails ensures it holds the patient safely without slipping, preventing injury or escape while allowing some movement. Loose restraints defeat the purpose, risking falls or harm. Applying to the strong arm alone ignores full safety needs restraints typically involve both limbs or a vest. Using them as punishment is unethical; they're for protection, not discipline. Nurses follow this technique to balance safety and ethics, monitoring frequently to minimize use and maintain dignity, per legal and care standards.

Correct Answer: C

Rationale: Demonstrating the technique and providing positive reinforcement encourages effective incentive spirometry use by showing proper deep-breathing methods and motivating the patient with praise, improving lung expansion post-surgery. Rapid breathing defeats the goal slow, deep breaths are key. Shallow breaths reduce efficacy, risking atelectasis. Using it for the patient undermines their active role it's a self-exercise tool. Nurses model the process, set goals (e.g., volume markers), and cheer progress, enhancing compliance and respiratory health through empowerment and support.

Correct Answer: D

Rationale: Cleansing from front to back during perineal care for a female patient prevents contamination by keeping fecal bacteria away from the urethra, reducing UTI risk a key hygiene principle. Back-to-front spreads pathogens, increasing infection likelihood. Cold water discomforts and doesn't clean better lukewarm is ideal. Avoiding soap neglects thoroughness; mild cleansers remove debris safely. Nurses use this directional technique with gentle wiping to maintain cleanliness and protect urinary health, especially in incontinent or dependent patients.

Correct Answer: A

Rationale: Holding the cane on the weaker side promotes safety by supporting the compromised leg, allowing the stronger side to bear weight naturally, enhancing balance during ambulation. Random cane placement reduces stability close, firm positioning is key. Tilting forward risks slipping or poor leverage; it should align vertically. Closed eyes disorient, increasing falls vision guides steps. Nurses ensure proper cane height and grip, reinforcing this technique to maximize support and minimize injury risk in mobility-limited patients.