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A nurse is collecting data from a client who has required strict bed rest for 1 week. Which of the following findings should the nurse identify as an indication that the client is ready to ambulate?

Develops fatigue when assisting with morning hygiene care

Needs assistance raising her legs to put on socks

Performs active range-of-motion (ROM) exercises of all extremities

Demonstrates mild dyspnea when eating breakfast

Answer and Explanation

The Correct Answer is C

A. Develops fatigue when assisting with morning hygiene care

Fatigue during hygiene suggests low endurance; not ready to ambulate safely.

B. Needs assistance raising her legs to put on socks

Needing assistance for simple tasks shows weakness and poor muscle control.

C. Performs active range-of-motion (ROM) exercises of all extremities

Performing full active ROM exercises indicates good muscle strength and coordination, suggesting readiness to attempt ambulation.

D. Demonstrates mild dyspnea when eating breakfast

Dyspnea with minimal activity (eating) indicates limited cardiopulmonary reserve-not yet fit to ambulate.

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Correct Answer is ["A","B","D"]

Explanation

A. Lock the wheels on beds and wheelchairs during transfers

Locking wheels prevents rolling, ensuring safety during movement.

B. Place the bedside table within the client's reach

Keeping frequently used items within reach reduces unnecessary movement and fall risk.

C. Keep the bed at a comfortable working height

The bed should be kept in the lowest position, not a working height, to reduce risk if the client tries to get up unassisted.

D. Keep a night light on in the client's room and bathroom

Adequate lighting prevents tripping and promotes safety during nighttime bathroom trips.

E. Administer a sedative at bedtime

Sedatives increase the risk of confusion, dizziness, and falls, especially in older adults.

A. speeding the drying with a hair dryer. B. elevating the leg on one to two pillows. C. petaling the edges of the cast. D. placing the patient in high Fowler's position.

Correct Answer is B

Explanation

A. Speeding the drying with a hair dryer:

This is not recommended as it can cause uneven drying and burns. Plaster casts must dry naturally.

B. Elevating the leg on one to two pillows:

Elevation promotes venous return and reduces swelling in the affected extremity.

C. Petaling the edges of the cast:

Petaling helps prevent skin breakdown from rough cast edges but does not affect edema.

D. Placing the patient in high Fowler's position:

This position benefits respiratory function but does not aid in reducing lower extremity edema.

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A nurse is collecting data from a client who has required strict bed rest for 1 week. Which of the following findings should the nurse identify as an indication that the client is ready to ambulate?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assisting with the development of a plan of care for an older adult who is at risk for falls. Which of the following actions should the nurse contribute to the plan? (Select all that apply)

Correct Answer is ["A","B","D"]

Explanation

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Correct Answer is B

Explanation

A nurse is collecting data from a client who has required strict bed rest for 1 week. Which of the following findings should the nurse identify as an indication that the client is ready to ambulate?

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