A nurse in a long-term care facility is assisting in planning care for a group of clients. For which of the following clients can the nurse safely gait belt?

A client who is displaying aggression

A client who has had chest trauma.

A client who has limited arm strength.

A client who has a thoracic incision.

Answer and Explanation

The Correct Answer is C

A. A client who is displaying aggression: Using a gait belt on an aggressive client is unsafe because sudden movements or resistance could lead to injury for both the client and the caregiver. Aggressive behavior requires de-escalation strategies before considering physical assistance or mobility interventions like a gait belt.

B. A client who has had chest trauma: Gait belts should be avoided in clients with chest trauma because the pressure applied around the torso can exacerbate injuries such as rib fractures, pulmonary contusions, or other thoracic complications, posing significant health risks during mobilization.

C. A client who has limited arm strength: A gait belt is appropriate for clients with limited arm strength because it provides secure support around the waist without requiring the client to rely heavily on their upper limbs. It allows for safer ambulation and transfer by offering the caregiver a firm point of control.

D. A client who has a thoracic incision: Applying a gait belt over or near a thoracic incision can interfere with wound healing, cause pain, and increase the risk of wound dehiscence. Alternative methods for assisting mobility should be used for clients with fresh surgical sites in the thoracic region.

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Correct Answer is C

Explanation

A. Open nearby doors and windows when the fire alarm sounds: Opening doors and windows during a fire can cause the fire to spread more rapidly by feeding it with additional oxygen. Doors should be closed to contain the fire and reduce the spread of smoke.

B. Attempt to extinguish the fire before evacuating clients: Client safety is the priority in a fire situation. Evacuation should occur first, and attempts to extinguish the fire should only be made if it is safe to do so without putting clients or staff at risk.

C. Have ambulatory clients walk independently to a safe location: Ambulatory clients should be instructed to evacuate independently if they can do so safely, freeing staff to assist clients who are immobile or require more help during the evacuation.

D. Aim the spray of the fire extinguisher at the top of the fire: The proper technique is to aim at the base of the fire, not the top, to effectively extinguish the flames by removing the fire's source of fuel.

A. Erythema B. Blood C. Edema D. Pruritus

Correct Answer is C

Explanation

A. Erythema: Erythema, or redness, is more commonly associated with phlebitis, an inflammation of the vein, rather than infiltration. While some redness may occur, it is not the primary or expected finding when infiltration is present.

B. Blood: The presence of blood at the insertion site may indicate a bleeding or hematoma issue but is not a typical sign of infiltration. Infiltration involves fluid, usually IV solution, leaking into surrounding tissue, not blood leaking out of the vein.

C. Edema: Edema at the insertion site is a hallmark sign of infiltration. When IV fluid escapes into the surrounding tissue instead of remaining in the vein, it causes localized swelling, coolness, and often discomfort or tightness around the insertion area.

D. Pruritus: Pruritus, or itching, is not a typical manifestation of infiltration. It may be seen with allergic reactions to IV medications or materials, but infiltration primarily presents with swelling, coolness, and sometimes blanching of the skin.

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A nurse in a long-term care facility is assisting in planning care for a group of clients. For which of the following clients can the nurse safely gait belt?

Nursing Test Bank

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