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 ["A","E"]

Explanation

A. Venous ulcers often have irregular wound borders. This is due to the underlying venous hypertension and tissue breakdown, which can lead to irregular shapes of the ulcer.

E. Significant edema, particularly in the lower leg and ankle area (often graded as +2 or +3), is commonly associated with venous ulcers. Venous insufficiency leads to fluid accumulation in the tissues, resulting in edema.

B. This is less likely to be associated with a venous ulcer. Venous ulcers typically occur on the lower leg, particularly around the medial or lateral malleolus, rather than on the plantar aspect of the foot.

C. Severe pain, especially on a scale of 9 out of 10, is less typical of venous ulcers. Venous ulcers are usually associated with mild to moderate discomfort or pain, often described as aching or heaviness rather than severe pain.

D. Venous ulcers typically exhibit moderate to heavy serous drainage. This is due to the chronic inflammation and venous congestion that characterize venous insufficiency.

A. experience any pain or burning on urination?" B. pass a little urine on a frequent basis?" C. feel that you are able to empty your bladder fully each time you void?" D. have a problem stopping or starting the flow of urine?"

Correct Answer is A

Explanation

A. This is the most direct and appropriate question to assess for dysuria. Dysuria is characterized by pain, discomfort, or burning sensation during urination. Asking this question helps the nurse to directly assess if the client is experiencing these symptoms.

B. This question is more relevant for assessing urinary frequency rather than dysuria. It is important for assessing other urinary symptoms but does not specifically address the characteristic pain or discomfort associated with dysuria.

C. This question is pertinent for assessing urinary retention or incomplete emptying of the bladder, which are different concerns from dysuria. It evaluates the client's perception of bladder emptying rather than pain or discomfort during urination.

D. This question is more relevant for assessing urinary hesitancy or urgency, which are related to bladder function but are not specific to dysuria. It addresses issues with urine flow dynamics rather than pain or discomfort during urination.

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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

Which of the following assessment findings would lead the nurse to suspect the client has a venous ulcer to the right lower extremity? (SELECT ALL THAT APPLY)

Correct Answer is ["A","E"]

Explanation

The nurse is assessing the client for the presence of dysuria. The nurse should ask: "Do you:

Correct Answer is A

Explanation

The nurse is completing a cardiac assessment on a client. The pulmonic valve would best be assessed by auscultating at the:

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A nurse is considering ethical principles during rounds. Which nursing statement demonstrates the principle of fidelity?

Which example best illustrates the principle of the nurse "knowing" the client? The nurse:

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