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.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

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

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is D

Explanation

A. Chicken broth is a clear liquid and would be appropriate for a clear liquid diet. However, it is not suitable for a full liquid diet because it is a clear liquid and does not represent the expanded options available on a full liquid diet.
B. Cranberry juice is a clear liquid and is appropriate for a clear liquid diet but is not typically included in the full liquid diet. While it is acceptable for hydration, it does not provide the more substantial nutrition options available in a full liquid diet.
C. Flavored gelatin is part of the clear liquid diet but is also compatible with the full liquid diet. It is liquid at room temperature and does not contain solid particles, making it an acceptable option for a full liquid diet.
D. Skim milk is considered a full liquid as it is liquid at room temperature and provides additional nutrients like protein and calcium that are beneficial for recovery. It is a suitable addition when progressing from a clear liquid diet to a full liquid diet.

A. Scrambled eggs B. Cottage cheese C. Piece of wheat toast D. Sliced banana

Correct Answer is C

Explanation

A. Scrambled eggs are soft, moist, and easy to chew and swallow, making them suitable for a mechanically altered diet.
B. Cottage cheese is soft and moist, which makes it easy to swallow and suitable for clients on a mechanically altered diet.
C. A piece of wheat toast is hard and dry, and it requires significant chewing. It is not suitable for a mechanically altered diet because it can pose a choking hazard and is difficult to swallow for individuals with chewing or swallowing difficulties.
D. Sliced banana is soft and moist, which makes it easy to chew and swallow. It is appropriate for a mechanically altered diet.

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

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is providing care for a client who is 2 days postoperative following abdominal surgery and is about to progress from a clear liquid diet to full liquids. Which of the following items should the nurse tell the client he may now request to have on his meal tray?

Correct Answer is D

Explanation

A nurse is caring for a client who is to receive a mechanically altered diet. Which of the following client food choices necessitates intervention by the nurse?

Correct Answer is C

Explanation

A nurse is reviewing the medication list for a client who has a new diagnosis of a small bowel obstruction. The nurse should withhold which of the following medications?

A nurse is assessing an adolescent female client who has anorexia nervosa. Which of the following findings should the nurse expect?

A nurse is taking a health history of a client who reports occasionally taking several over-the- counter medications, including an H2 receptor antagonist (HRA). Which of the following outcomes indicates the H2RA is therapeutic?

A nurse in a clinic is teaching the mother of a 4-month-old infant who has been breastfed. The mother plans to switch her infant to an iron- fortified formula. Which of the following should be included in the teaching?

A charge nurse observes a nurse administer intermittent tube feedings via an NG tube to a client. Which of the following actions should prompt the charge nurse to intervene?

A nurse is caring for a client who has impaired renal function. For which of the following findings should the nurse notify the provider?

A nurse is assisting a client who is postpartum with her first breastfeeding experience. When the client asks how much of the nipple she should put into the newborn's mouth, which of the following responses should the nurse make?

A nurse is teaching a client about crutch walking using the three-point gait. Which of the following statements by the nurse should be included in the teaching?