A nurse is preparing a client for ambulation. Which of the following actions should the nurse take to determine the client's level of strength?

Palpate the client's pedal pulses.

Ask the client how strong she feels today.

Ask the client to touch her finger to her nose.

Ask the client to push her feet against the nurse's palms.

Answer and Explanation

The Correct Answer is D

A.   Palpating the pedal pulses is important for assessing circulation and vascular status, not for evaluating muscle strength. This action helps in determining blood flow to the lower extremities but does not provide information about the client’s muscle strength or ability to ambulate.
B.   Asking the client how strong she feels provides subjective information about her perceived strength but does not objectively assess muscle strength. This method relies on the client's self-assessment, which may not always be accurate or reliable.
C.   Touching the finger to the nose is a test of coordination and can help assess motor function and neurological status. While it provides information about coordination, it does not specifically measure the client’s overall muscle strength, especially in the lower extremities, which is critical for safe ambulation.
D.   Asking the client to push her feet against the nurse’s palms is an effective way to assess lower
extremity muscle strength. This action allows the nurse to gauge the client’s ability to exert force with
their legs, which is essential for ambulation and overall mobility.

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Correct Answer is A,B,D,C

Explanation

A. Verify tube placement: This is the first step to ensure that the tube is in the correct position and not in the lungs, which could lead to aspiration.

B. Check the residual feeding contents: This helps to assess gastric emptying and ensure that the stomach can tolerate the feeding. If there is a large amount of residual, the feeding may be delayed or the rate may need to be adjusted.

D. Administer the feeding: Once tube placement is confirmed and residual contents are assessed, the feeding can be administered at the prescribed rate.

C. Evaluate tolerance of feeding: After the feeding is complete, it's important to monitor the client for signs of tolerance, such as the absence of nausea, vomiting, or abdominal distension.

A. Iron facilitates development of vision in infants. B. Iron stores in infants begin to deplete. C. Iron facilitates growth of bones in infants. D. Iron is poorly absorbed in infants.

Correct Answer is B

Explanation

A. While iron is crucial for overall health, its primary role in infants is not specifically related to vision development. Iron is essential for many bodily functions, including oxygen transport and brain development, but the statement about vision development is not directly relevant to the primary reasons for iron supplementation in infants.
B. This is a key point to include in the teaching. Iron stores that infants are born with start to deplete around 4-6 months of age. This is why iron-fortified formula or iron-rich complementary foods are recommended to prevent iron deficiency anemia, as breast milk alone may not provide sufficient iron after this period.
C. Iron is important for overall growth and development, including the development of red blood cells and cognitive functions. However, the specific facilitation of bone growth is more directly related to other nutrients like calcium and vitamin D.
D. Iron absorption can be a concern, but this statement is not entirely accurate. Iron in formula is typically well-absorbed, especially in iron-fortified formulas designed for infants. The goal of providing iron-fortified formula is to ensure that the infant receives an adequate amount of iron, which is absorbed effectively to support their growing needs.

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A nurse is preparing a client for ambulation. Which of the following actions should the nurse take to determine the client's level of strength?

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Naxlex Comprehensive Predictor Exams

A nurse is preparing to administer an enteral feeding via nasogastric tube. Identify the correct sequence the nurse should follow to initiate the feeding. (Move the steps, placing them in the selected order of performance. All steps must be used.)

Correct Answer is A,B,D,C

Explanation

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Correct Answer is B

Explanation

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