Prior to obtaining a trapeze bar for a client with limited mobility, which client assessment is most important for the nurse to obtain?

Balance and posture.

Risk for disuse syndrome.

Pressure sore risk.

Upper body muscle strength.

Answer and Explanation

The Correct Answer is D

Rationale:
A. Balance and posture: Although relevant for general mobility, a trapeze bar is primarily used while in bed, where balance and posture are less critical than the strength to use the device effectively.

B. Risk for disuse syndrome: This risk supports the need for mobility aids like a trapeze, but it does not determine whether the client can use the device safely and independently.

C. Pressure sore risk: This is important for overall care planning, but not the most relevant assessment for determining safe and effective trapeze use.

D. Upper body muscle strength: Adequate arm and shoulder strength are essential for the client to grasp and lift themselves using the trapeze bar. Without this, using the bar could lead to falls or injuries.

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 C

Explanation

Rationale:

A. Assess lung sounds for signs of infection: While lung assessment is important, there's no indication of fever or increased sputum to suggest infection. It does not immediately relieve the client's current dyspnea.

B. Encourage client to initiate a smoking cessation program: Smoking cessation is vital but is a long-term intervention and not appropriate as the first action for acute shortness of breath following exertion.

C. Administer a prescribed albuterol inhaler: Albuterol acts as a bronchodilator and can relieve acute shortness of breath due to bronchospasm or exertional dyspnea in clients with emphysema. This is the most immediate and appropriate action.

D. Notify the healthcare provider of the low pulse oximetry value: Although communication with the provider may be needed if symptoms persist, the pulse ox of 88% can be common in COPD clients. Immediate symptom relief with the prescribed bronchodilator is the priority.

A. Blood pressure of 120/74 mm Hg B. Capillary refill of 4 seconds in lower extremities C. Pedal pulse of 2+ or better D. Pupils equal and nonresponsive to light E. Absence of numbness or tingling in feet F. Skin that is pale, cool to touch G. Client has urine output of 1,600 mL in 24 hours H. Creatinine of 1.2 mg/dL (106 mmol/L)

Correct Answer is ["A","C","E","G","H"]

Explanation

Rationale for Correct Choices:

Blood pressure of 120/74 mm Hg: This is within the normal range and indicates stable cardiovascular function, which supports discharge readiness following an aortic aneurysm intervention.
Pedal pulse of 2+ or better: A 2+ pulse signifies adequate peripheral perfusion. It is important for assessing vascular integrity postoperatively, especially for patients with a history of aneurysmal disease.
Absence of numbness or tingling in feet: Normal neurovascular sensation in the lower extremities suggests intact peripheral nerve and vascular supply, a critical discharge criterion after vascular complications.
Client has urine output of 1,600 mL in 24 hours: This volume reflects adequate renal perfusion and fluid balance, within the normal range (800-2000 mL/day for adults) both of which are necessary to confirm the kidneys are functioning properly post-recovery.
Creatinine of 1.2 mg/dL (106 mmol/L): This value is within normal limits (0.6-1.2 mg/dL), indicating that renal function is preserved and not compromised by the previous cardiovascular event or interventions.

Rationale for Incorrect Choices:

Capillary refill of 4 seconds in lower extremities: A capillary refill time longer than 2–3 seconds suggests impaired perfusion, which would warrant further evaluation before discharge.
Pupils equal and nonresponsive to light: This indicates a serious neurological deficit, potentially related to brain injury or altered consciousness, and is incompatible with safe discharge.
Skin that is pale, cool to touch: This suggests possible peripheral hypoperfusion or systemic circulatory compromise and would need to be resolved before considering discharge.

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

Body system	Findings
Cardiovascular	Blood pressure of 120/74 mm Hg Capillary refill of 4 seconds in lower extremities Pedal pulse of 2+ or better
Neurovascular	Pupils equal and nonresponsive to light Absence of numbness or tingling in feet Skin that is pale, cool to touch
Renal Perfusion	Client has urine output of 1,600 mL in 24 hours Creatinine of 1.2 mg/dL (106 mmol/L)

Prior to obtaining a trapeze bar for a client with limited mobility, which client assessment is most important for the nurse to obtain?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is C

Explanation

Correct Answer is ["A","C","E","G","H"]

Explanation

A client with Neisseria meningitidis calls the nurses station to report a severe headache and vomiting. The unlicensed assistive personnel (UAP) approaches the room to provide an emesis basin and is stopped by the nurse. Which action should the nurse take?

The nurse observes a practical nurse (PN) placing a client on the right side with the left leg bent in preparation for a lumbar puncture. Which action should the nurse implement?

A client who weighs 110 lb receives a prescription for dalteparin 150 units/kg SUBQ daily for 4 months. The medication is available in 7,500 units/0.3 mL prefilled syringe. How many mL should the nurse administer? (Enter numerical value only.)

The first paddle has been placed on the chest of a client who needs defibrillation. Where should the nurse place the second paddle? (Mark the location where the second paddle should be placed on the image)

The school nurse is preparing a presentation for elementary school teachers to inform them when a child should be referred to the school clinic for further follow-up. The teachers should be instructed to report which situations to the school nurse? Select all that apply.