A client has been on bed rest following a cerebrovascular accident or stroke that occurred two days ago. On the third day, the plan of care includes getting the client out of bed and into a bedside chair. Prior to assisting the client out of bed for the first time, which action should the nurse take?

Assess the client's brain stem reflexes.

Perform pupillary response assessment.

Assess the client's blood pressure.

Offer the client to void before getting out of bed.

Answer and Explanation

The Correct Answer is C

A.   While assessing brain stem reflexes can provide valuable information about the neurological status of the client, it is not the immediate priority when preparing to move a client from bed to a chair. Brain stem reflexes are more relevant for assessing overall neurological function and response to stimuli, but they do not directly inform the safety and readiness of the client for physical activity.
B.   Assessing the pupillary response is important for evaluating neurological function and consciousness levels. However, it is not directly related to assessing the client’s readiness to be moved from bed to a chair. Pupillary response does not provide specific information about the client’s hemodynamic stability or immediate readiness for physical activity.
C.   Assessing the client’s blood pressure is crucial, especially after a stroke, as the client may be at risk for orthostatic hypotension (a sudden drop in blood pressure when standing up). Checking blood pressure helps ensure that the client is hemodynamically stable and can tolerate the change in position without risking dizziness, fainting, or other complications.
D.   Offering the client the opportunity to void before getting out of bed is a practical measure to ensure comfort and avoid accidents. It helps prevent the need for the client to seek the bathroom immediately after being moved to the chair, which could be disorienting or potentially hazardous.

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Correct Answer is D

Explanation

A. Decreasing the rate of the feeding might be a consideration if the feeding was too rapid, but it is not the immediate priority if aspiration is suspected.
B. While it is important to monitor for allergic reactions to enteral formulas, this is not the immediate concern if aspiration is suspected. Allergic reactions would typically present with symptoms such as rash, itching, or gastrointestinal distress, and not immediately after aspiration.
C. Hanging a new bag of enteral formula is not an appropriate action if aspiration is suspected. The
priority is to ensure the client’s safety and address any complications that may arise from the aspiration, such as aspiration pneumonia.
D. Stopping the tube feeding and assessing the client is the most appropriate initial action if aspiration is suspected. Immediate assessment is necessary to determine if the client is experiencing signs of aspiration, such as coughing, wheezing, difficulty breathing, or changes in consciousness.

A. Offer to adjust the height of the walker. B. Explain the need to remove the wheels from the walker. C. Demonstrate more coordinated movement of the legs and walker. D. Encourage the client to continue using the walker as observed.

Correct Answer is A

Explanation

A. The walker should be adjusted to the client's height so that their elbows are slightly flexed when grasping the hand bars. This allows for proper weight-bearing and reduces strain on the shoulders and arms. Using a walker that is the correct height can help to prevent falls by providing better stability and support.
B. Removing the wheels from the walker would make it difficult for the client to use. The wheels are an important feature of a walker, as they allow the client to move more easily.
C. While demonstrating more coordinated movement may be helpful, it's not the most immediate action needed. Adjusting the height of the walker is a more important step to ensure the client's safety and comfort.
D. Encouraging the client to continue using the walker as observed may not be appropriate if the walker is not adjusted to the correct height. A properly adjusted walker is essential for safe and effective mobility.

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Naxlex Comprehensive Predictor Exams

A client with a gastrostomy tube is receiving a continuous feeding, and the nurse suspects that the client has aspirated some of the feeding. Which action should the nurse take?

Correct Answer is D

Explanation

A client is ambulating with a two wheeled walker by rolling the walker forward and then moving each foot forward. The nurse notes that the client's elbows are slightly flexed when grasping the hand bar. After the client returns to the chair, which action should the nurse implement?

Correct Answer is A

Explanation

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