A nurse is getting a client out of bed to ambulate for the first time.

The client is pale, diaphoretic, has a pulse of 100/minute, and says, “I feel weak.

Let me sit on the side of the bed for a minute.” What finding should the nurse document?

A normal reaction to a position change.

Gait belt applied.

Orthostatic hypotension noted with dangling.

Elevated blood sugar probable.

Answer and Explanation

The Correct Answer is C

Orthostatic hypotension noted with dangling.

This means that the client’s blood pressure drops when changing position from lying down to sitting or standing. This can cause symptoms such as paleness, sweating, rapid pulse, weakness, and dizziness.

The nurse should document this finding and report it to the physician.

Choice A is wrong because a normal reaction to a position change would not cause such severe symptoms.

Choice B is wrong because the gait belt applied is not a finding but an intervention.

Choice D is wrong because elevated blood sugar probable is not a finding but a speculation.

Choice E is wrong because spot accucheck obtained is not a finding but an action.

Choice F is wrong because fear of falling expressed by a client is not a finding related to the client’s vital signs or physical condition.

Choice G is wrong because provided reassurance is not a finding but a nursing measure.

Nursing Test Bank

Test Bank #1: RN Pharmacology Exams Test Bank #2: RN Medical-Surgical Exams Test Bank #3: RN Fundamentals Exams Test Bank #4: RN Maternal-Newborn Exams Test Bank #5: RN Anatomy and Physiology Exams Test Bank #6: RN Obstetrics and Pediatrics Exams Test Bank #7: RN Fluid and Electrolytes Exams Test Bank #9: RN Adult Health Test Bank #10: RN Dosage Calculation Test Bank #11: RN Community Health Exams Test Bank #12: RN Psychology Exams Test Bank #13: RN Nursing Care Of Children Test Bank #14: RN Foundations of Nursing Exams

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

Naxlex Comprehensive Predictor Exams

Exam #1: RN Comprehensive predictor 2023 proctored exam Exam #2: Ati rn vati comprehensive predictor proctored exam Exam #3: Ati Rn Comprehensive Predictor Proctored Exam 2023 Exam #4: Rn Comprehensive Predictor 2023 Proctored Exam - St. Joseph Exam #5: RN Comprehensive Predictor Proctored Exam (National U CA San Diego) Exam #6: Ati rn comprehensive predictor 2023 retake proctored exam Exam #7: RN Hesi Exit Proctored Exam Exam #8: Hesi RN Exit proctored exam Exam #9: Hesi rn exit proctored exam Exam #10: Hesi Rn compass exit B proctored exam

Free Nursing Study Resources

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

Explanation

These nursing interventions can help promote bowel movement and prevent constipation. According to, constipation is a common gastrointestinal symptom caused by various factors such as a low-fiber diet, inadequate fluid intake, decreased gastrointestinal motility, medication use, and insufficient activity.

Therefore, encouraging high-fiber food choices, increasing fluid intake to 2,000 mL per day, and encouraging ambulation several times daily are appropriate interventions to address these factors and improve bowel function.

Choice D is wrong because administering antacids as necessary per the bowel management program is not a nursing intervention for constipation.

Antacids are used to neutralize stomach acid and relieve heartburn or indigestion.

They do not have any effect on bowel movement or constipation. In fact, some antacids may cause constipation as a side effect.

Therefore, this intervention is not relevant to the plan of care for a client diagnosed with constipation.

A. TMS requires anesthesia prior to administration. B. TMS requires a muscle relaxing medication prior to administration. C. TMS requires the patient to lay flat in bed during administration. D. TMS requires daily treatments for 4 to 6 weeks.

Correct Answer is D

Explanation

TMS requires daily treatments for 4 to 6 weeks. This is because TMS is a noninvasive procedure that uses magnetic fields to stimulate nerve cells in the brain to improve symptoms of depression. TMS is typically used when other depression treatments haven’t been effective. The treatment can last 30 to 60 minutes and is done 5 days a week for about 4 to 6 weeks.

Choice A is wrong because TMS does not require anesthesia prior to administration. The procedure is done without using surgery or cutting the skin and the patient is awake throughout the treatment.

Choice B is wrong because TMS does not require a muscle-relaxing medication prior to administration. The procedure does not cause muscle contractions or spasms and the patient can resume normal activities after the treatment.

Choice C is wrong because TMS does not require the patient to lay flat in bed during administration. The procedure is done in a comfortable chair and the patient can drive themselves home after the treatment.

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 nurse is getting a client out of bed to ambulate for the first time. The client is pale, diaphoretic, has a pulse of 100/minute, and says, “I feel weak. Let me sit on the side of the bed for a minute.” What finding should the nurse document?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is developing a plan of care for a client diagnosed with constipation. Which nursing interventions should be included in planning? (Select all that apply).

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

Explanation

A nurse should include which statement when instructing a client about Transcranial Magnetic Stimulation (TMS).

Correct Answer is D

Explanation

A nurse enters a client’s room and finds the client’s gown is on fire. Which is the nurse’s priority action?

The family of a client that has been diagnosed with terminal cancer decided not to inform the client of the prognosis. What is the most appropriate action for a nurse to take when the client repeatedly asks about prognosis?

Which response by the client indicates that medication instruction by the RN has been effective?

Which action should the nurse take after assessing a 2-day-old wound that has a crust along the edges, is red and appears slightly swollen?

Which action will prevent spreading organisms from one eye to the other when bathing a client?

Which technique is most reliable to confirm correct placement of a nasogastric tube prior to initiating tube feedings?

Which technique is most appropriate for a nurse to use when cleansing a pressure ulcer?

A nurse is teaching a client with newly diagnosed hemophilia about home care practices. What statements by the client indicate that teaching has been effective? Select all that apply.

A nurse is getting a client out of bed to ambulate for the first time.

The client is pale, diaphoretic, has a pulse of 100/minute, and says, “I feel weak.

Let me sit on the side of the bed for a minute.” What finding should the nurse document?