A client has little use of the left side due to a stroke. To assist with ambulation for the first time, the nurse should walk:
directly in front of the client.
along the affected left side.
directly behind the client.
along the unaffected right side.
The Correct Answer is B
Choice A reason: This is incorrect. Walking directly in front of the client may block their view and increase their risk of falling. The nurse should walk to the side and slightly behind the client to provide support and guidance³.
Choice B reason: This is correct. Walking along the affected left side allows the nurse to assist the client with balance, weight shifting, and foot clearance. The nurse should also encourage the client to use the handrail on their strong side³.
Choice C reason: This is incorrect. Walking directly behind the client may not allow the nurse to see the client's gait pattern or intervene quickly if the client loses balance. The nurse should walk to the side and slightly behind the client to monitor and assist them³.
Choice D reason: This is incorrect. Walking along the unaffected right side may not provide adequate support or protection for the client's affected side. The nurse should walk along the affected left side to help the client with their hemiplegic gait³.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A reason: Providing education to the client about the procedure is not the action that the nurse should implement first. This action is important, but not urgent. The nurse should prioritize the assessment and monitoring of the client's physical status and potential complications.
Choice B reason: Assessing vital signs and catheter insertion site is the action that the nurse should implement first. This action is essential to evaluate the client's hemodynamic stability and to detect any signs of bleeding, hematoma, infection, or vascular injury at the site of catheter insertion. The nurse should also check the peripheral pulses and sensation of the affected extremity.
Choice C reason: Administering fluids to provide hydration is not the action that the nurse should implement first. This action may be indicated to prevent contrast-induced nephropathy or dehydration, but it is not the priority. The nurse should first assess the client's fluid status and renal function before administering fluids.
Choice D reason: Administering the prescribed dose of aspirin and metoprolol is not the action that the nurse should implement first. This action may be indicated to prevent thrombosis or ischemia, but it is not the priority. The nurse should first assess the client's cardiac status and contraindications before administering these medications.
Correct Answer is B
Explanation
Choice A reason: Admission blood pressure is 110/70 is not the information that the nurse must report to the health care provider prior to the procedure. This is a normal blood pressure reading for an adult client and does not indicate any contraindication or complication for the cardiac angiogram.
Choice B reason: Client has multiple food and drug allergies is the information that the nurse must report to the health care provider prior to the procedure. This is a critical information that may affect the choice of contrast agent, medications, or equipment used for the cardiac angiogram. The nurse should identify the specific allergens and the type and severity of the allergic reactions that the client has experienced in the past.
Choice C reason: Pedal pulses are 1+ bilaterally is not the information that the nurse must report to the health care provider prior to the procedure. This is a low-normal finding for the strength of the peripheral pulses and does not indicate any significant vascular impairment or obstruction. The nurse should document and monitor the pedal pulses, but not necessarily report them.
Choice D reason: Client is slightly anxious is not the information that the nurse must report to the health care provider prior to the procedure. This is a common and expected emotional response for a client who is undergoing an invasive diagnostic test and does not require any immediate intervention. The nurse should provide reassurance and education to the client and address any concerns or questions that they may have.
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