A nurse is planning to assist a client who has left-sided weakness to ambulate using a gait belt. Which of the following actions should the nurse plan to take?
Walk on the client's right side.
Instruct the client to look down at their feet when ambulating.
Have the client sit on the side of the bed for at least 60 seconds before ambulating.
Place the gait belt securely around the client's lower chest.
The Correct Answer is C
The correct answer is C.
Choice A reason: Walking on the client’s right side is incorrect because the nurse should walk on the client’s left side. This is the weaker side and the side where support is most needed.
Choice B reason: Instructing the client to look down at their feet when ambulating is incorrect because the client should be instructed to look straight ahead, not down at their feet, to maintain balance and prevent falls.
Choice C reason: Have the client sit on the side of the bed for at least 60 seconds before ambulating. This allows the nurse to assess the client’s tolerance and readiness for ambulation, and it helps prevent dizziness or fainting due to orthostatic hypotension.
Choice D reason: Placing the gait belt securely around the client’s lower chest is incorrect because the gait belt should be placed around the client’s waist, not the lower chest. This provides a secure grip for the nurse and allows for safer ambulation.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale:
Instructing the client's loved ones that the client should not have fresh flowers in their room (Choice A) is not a necessary action for rubella isolation. Rubella is transmitted through respiratory droplets, and the prohibition of fresh flowers is not a relevant precaution.
Choice B rationale:
Wearing a surgical mask when within 0.9 m (3 feet) of the client (Choice B) is the correct action. Rubella is an airborne disease, and wearing a surgical mask helps prevent the spread of infectious respiratory droplets to the nurse and other individuals.
Choice C rationale:
Placing the client in a room with negative-airflow pressure (Choice C) is not specifically indicated for rubella isolation. Negative-airflow pressure rooms are typically used for diseases that require strict airborne precautions, such as tuberculosis.
Choice D rationale:
Instructing the client that visitors will not be allowed while they are in isolation (Choice D) is not entirely accurate for rubella isolation. While isolation precautions are necessary, visitors can enter the room if they are properly protected, including wearing masks and following infection control protocols.
Correct Answer is B
Explanation
Choice A rationale:
1 cup of shredded lettuce is low in potassium and is not the best source of potassium for a client with heart failure. While vegetables like lettuce are generally healthy, they do not provide a significant amount of potassium.
Choice B rationale:
1 cup of cantaloupe is the best source of potassium among the given options. Cantaloupe is a fruit that contains a moderate amount of potassium. Including this fruit in the client's diet can help maintain a balanced potassium level, which is important for heart health.
Choice C rationale:
1 oz of tuna is a source of protein but is not particularly rich in potassium. While protein intake is important for overall health, other choices on the list provide more potassium, which is specifically needed for clients with heart failure.
Choice D rationale:
1 cup of raspberries is a good source of fiber and antioxidants, but it is not as rich in potassium as cantaloupe. While raspberries can be a healthy addition to the diet, they are not the best choice for addressing potassium needs in this scenario.
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