The nurse will be assisting the client to walk. What should the nurse do first?

Assist the client to a sitting position at the side of the bed

Determine the client's strength, coordination, and activity tolerance

Help the client into a standing position

Ask another nurse for assistance

Answer and Explanation

The Correct Answer is B

B. Such an assessment helps in determining the level of assistance the client will need and ensures the safety of both the client and the nurse.

A. Helping the client to sit at the edge of the bed allows them to acclimate to being upright, assess their readiness to stand, and ensures their safety before attempting to walk. However, it is not the priority.

C. After assisting the client to a sitting position at the edge of the bed and assessing their readiness, the nurse can proceed to help the client into a standing position. However, it is not the priority.

D. This option may be necessary if the client requires two-person assistance due to their condition, mobility status, or safety concerns. However, asking for assistance typically comes after assessing the client's readiness and ensuring they are positioned correctly for ambulation.

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Correct Answer is D

Explanation

D. Rectal temperature measurement involves inserting a thermometer into the rectum. This method provides the most accurate reflection of core body temperature because the rectum closely mirrors internal body temperature. It is often used in infants, young children, and patients who are unable to have their temperature taken orally.

A. Axillary temperature measurement involves placing the thermometer in the armpit. This method is convenient and non-invasive but tends to provide the lowest temperature readings compared to other sites. It is suitable for screening purposes but may not be as accurate as other methods.

B. Skin temperature can vary widely based on environmental factors, circulation, and local skin conditions. Surface skin temperature may not accurately reflect core body temperature and is not typically used for precise temperature measurement in clinical settings.

C. Oral temperature measurement involves placing the thermometer under the tongue. This method is commonly used and provides a reasonably accurate reflection of core body temperature. It is convenient and generally well-tolerated by clients who are conscious and able to cooperate.

A. Confusion B. Apnea C. Cyanosis D. Dysrhythmias

Correct Answer is A

Explanation

A. Confusion can be an early sign of hypoxia, especially when oxygen delivery to the brain is compromised. Inadequate oxygenation can affect cognitive function and mental status, leading to confusion. This occurs because the brain is highly sensitive to changes in oxygen levels.

B. Apnea refers to the absence of breathing. While severe hypoxia can lead to respiratory arrest and apnea, it is not typically an early manifestation of hypoxia. Early hypoxia is characterized by attempts to increase ventilation to compensate for decreased oxygen levels, rather than complete cessation of breathing.

C. Cyanosis occurs when there is a bluish discoloration of the skin and mucous membranes due to deoxygenated hemoglobin in the blood. Cyanosis is a late sign of hypoxia and usually indicates significant oxygen deprivation. It is not typically seen in early hypoxia stages.

DDysrhythmias (irregular heart rhythms) can occur as a result of hypoxia, especially if the heart muscle is not receiving enough oxygen. However, dysrhythmias are generally considered a later manifestation of hypoxia, as the heart attempts to compensate for decreased oxygen delivery.

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The nurse will be assisting the client to walk. What should the nurse do first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is D

Explanation

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Correct Answer is A

Explanation

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