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.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is C

Explanation

Choice A reason: Divalproex is not used for treating acute dystonic reactions.

Choice B reason: Lorazepam can be used for certain types of acute reactions but is not the first line of treatment for dystonic reactions with laryngeal spasm.

Choice C reason: IV administration of benztropine is appropriate for treating acute dystonic reactions, including laryngeal spasm, as it helps to relieve the muscle contractions.

Choice D reason: IV administration of isotonic crystalloid fluid is not a treatment for dystonic reactions but may be used to maintain hydration and electrolyte balance.

A. Turn every 2 hours around the clock from side-to-side. B. Record the amount of daily wound drainage. C. Assess skin condition and turgor for breakdown. D. Replace fluids IV based on intake and output.

Correct Answer is D

Explanation

Choice A reason: Turning every 2 hours is important for preventing pressure ulcers but is not the primary concern for a client with severe ulcerative colitis and recent surgery.

Choice B reason: Recording wound drainage is necessary but not the most critical intervention compared to fluid balance.

Choice C reason: Assessing skin condition is important but secondary to maintaining fluid balance in a critically ill client.

Choice D reason: Replacing fluids based on intake and output is crucial to manage dehydration and electrolyte imbalances, which are common in clients with severe ulcerative colitis.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

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

A client experiencing an acute dystonic reaction presents with a laryngeal spasm. Which treatment should the nurse prepare?

Correct Answer is C

Explanation

A client with a history of inflammatory bowel disease develops severe ulcerative colitis and is admitted to the intensive care unit after surgery for a fistula repair. Which intervention is most important for the nurse to include in the plan of care?

Correct Answer is D

Explanation

A client newly diagnosed with diabetes mellitus suddenly becomes confused and weak. Which intervention(s) should the nurse implement? Select all that apply.

The nurse is preparing to administer a formula feeding by nasogastric tube (NGT) to a 2-month-old. Which intervention should the nurse implement?

The nurse is providing education to a client who receives a prescription for zolpidem. Which information about the medication should the nurse include?

A client expresses concern about receiving proper care in accordance with the client's religion. Which action is best for the nurse to take?

A client presents to the emergency department (ED) reporting abdominal pain. The nurse observes the client's right cheek and eye are bruised and suspects possible domestic violence. Which approach is best for the nurse to use when interviewing the client?

The school nurse is preparing a teaching pamphlet in response to requests from parents regarding an outbreak of pinworms at the local preschool. Which information about the most commonly prescribed medication, mebendazole, should be included?

A client who fell and broke a wrist is admitted for 24-hour observation after emergency orthopedic surgery. The healthcare provider prescribes discharge in the morning. Which finding(s) should the nurse use to evaluate the client's status for discharge from the hospital? Select all that apply.

A postoperative client returns to the nursing unit following a ureterolithotomy via a flank incision. Which potential problem has the highest priority when planning nursing care for this client?