A client with limited tolerance for activity needs to walk in the hallway with assistance. Which instruction(s) should the nurse give to the unlicensed assistive personnel (UAP) who is assisting with the client's care? Select all that apply.

Measure the client's vital signs before the client walks.

Determine if the client needs to have a gait belt applied.

Report the onset of any dizziness or lightheadedness.

Instruct the client about signs of orthostatic hypotension.

Offer to assist the client to void prior to walking in the hall.

Answer and Explanation

Correct Answer : A,C,E

Choice A reason: Measuring the client's vital signs before walking helps ensure the client's stability and readiness for activity.

Choice B reason: Determining the need for a gait belt is typically the responsibility of the nurse, not the UAP.

Choice C reason: Reporting dizziness or lightheadedness is important for monitoring the client's response to activity and preventing falls.

Choice D reason: Instructing the client about orthostatic hypotension is not within the scope of practice for a UAP.

Choice E reason: Assisting the client to void before walking can prevent discomfort and the need for an urgent restroom break during the activity.

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Correct Answer is A

Explanation

Choice A reason: A history of suicide attempts is crucial information when planning the care of a client using heroin because there is a high risk of further suicide attempts, especially in individuals with substance use disorders. The nurse must prioritize mental health safety and implement measures to monitor and support the client's psychological well-being to prevent any potential self-harm.

Choice B reason: While family history of schizophrenia is important, it is not immediately crucial to the plan of care for a client currently using heroin. This information is more relevant for long-term monitoring and psychiatric evaluation rather than immediate care planning.

Choice C reason: Undiagnosed social anxiety disorder (SAD) may contribute to substance use; however, it is not the most urgent concern in this scenario. The focus should be on immediate safety and stabilization, particularly addressing the high risk of suicide.

Choice D reason: Feelings of disorientation are significant but could be a result of heroin use. While important to assess, they are secondary to the immediate concern of preventing self-harm in a client with a history of suicide attempts.

Correct Answer is ["1000"]

Explanation

Calculation Steps:

Step 1: Determine the total volume to be infused: 500 mL. Result = 500 mL.

Step 2: Convert time from minutes to hours: 30 minutes ÷ 60 minutes/hour = 0.5 hours. Result = 0.5 hours.

Step 3: Calculate the infusion rate: 500 mL ÷ 0.5 hours = 1000 mL/hour.

Result = 1000 mL/hour.

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A client with limited tolerance for activity needs to walk in the hallway with assistance. Which instruction(s) should the nurse give to the unlicensed assistive personnel (UAP) who is assisting with the client's care? Select all that apply.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

During an admission assessment, a client reports currently using heroin. Which information is most important for the nurse to consider in the plan of care?

Correct Answer is A

Explanation

The healthcare provider (HCP) prescribes 0.9% normal saline 500 mL IV bolus to be infused over 30 minutes. How many mL/hour should the nurse set the infusion pump? (Enter numerical value only.)

Correct Answer is ["1000"]

Explanation

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