A nurse in a long-term care facility is assisting in planning care for a group of clients. For which of the following clients can the nurse safely gait belt?

A client who is displaying aggression

A client who has had chest trauma.

A client who has limited arm strength.

A client who has a thoracic incision.

Answer and Explanation

The Correct Answer is C

A. A client who is displaying aggression: Using a gait belt on an aggressive client is unsafe because sudden movements or resistance could lead to injury for both the client and the caregiver. Aggressive behavior requires de-escalation strategies before considering physical assistance or mobility interventions like a gait belt.

B. A client who has had chest trauma: Gait belts should be avoided in clients with chest trauma because the pressure applied around the torso can exacerbate injuries such as rib fractures, pulmonary contusions, or other thoracic complications, posing significant health risks during mobilization.

C. A client who has limited arm strength: A gait belt is appropriate for clients with limited arm strength because it provides secure support around the waist without requiring the client to rely heavily on their upper limbs. It allows for safer ambulation and transfer by offering the caregiver a firm point of control.

D. A client who has a thoracic incision: Applying a gait belt over or near a thoracic incision can interfere with wound healing, cause pain, and increase the risk of wound dehiscence. Alternative methods for assisting mobility should be used for clients with fresh surgical sites in the thoracic region.

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Free Nursing Study Resources

Correct Answer is A

Explanation

A. Place the client in a room near the nurses' station: Clients with quadriplegia are at high risk for complications such as respiratory difficulties, pressure injuries, and autonomic dysreflexia. Placing them near the nurses’ station allows for closer monitoring and quicker response to any urgent needs.

B. Check on the client every 4 hr: Clients with quadriplegia require more frequent monitoring than every 4 hours. Regular repositioning, skin assessments, and prompt attention to needs must occur at much shorter intervals to prevent complications.

C. Place the call light within the client's reach: A client with quadriplegia typically has limited or no use of their upper extremities. Therefore, they would be unable to effectively use a standard call light and would need alternative methods, such as a specialized call device.

D. Place the client's glasses on the bedside table: If the client is unable to move their arms due to quadriplegia, placing glasses on the bedside table would not be useful. Necessary personal items should be made accessible through assistance or adaptive equipment.

A. Anorexia B. Epistaxis C. Weight gains D. Bradycardia

Correct Answer is B

Explanation

A. Anorexia: Anorexia, or loss of appetite, is not a typical adverse effect directly associated with heparin use. While it may occur due to general postoperative factors, it is not an urgent or life-threatening reaction that necessitates immediate reporting related to anticoagulant therapy.

B. Epistaxis: Epistaxis, or nosebleed, is a sign of potential bleeding complications, which is a major adverse effect of heparin. Because heparin inhibits clot formation, any evidence of spontaneous bleeding must be reported immediately to the provider to assess for potential heparin-induced bleeding disorders.

C. Weight gain: Weight gain could suggest fluid retention, but it is not a typical adverse effect of heparin. While postoperative clients should be monitored for signs of fluid imbalance, sudden bleeding signs like epistaxis are far more critical to recognize and report when administering anticoagulants.

D. Bradycardia: Bradycardia, or slow heart rate, is not commonly linked to heparin therapy. While abnormal heart rhythms may occur postoperatively for other reasons, they are not typically associated with bleeding risks from heparin and thus do not require urgent reporting specific to heparin use.

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A nurse in a long-term care facility is assisting in planning care for a group of clients. For which of the following clients can the nurse safely gait belt?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assisting in the care of a client who has quadriplegia. Which of the following actions should the nurse take?

Correct Answer is A

Explanation

A nurse is caring for a client who is 1 day postoperative following a total hip arthroplasty and is receiving heparin subcutaneously. Which of the following adverse effects of the medication should the nurse report to the provider?

Correct Answer is B

Explanation

A nurse is caring for a client who has schizophrenia and is refusing to take a prescribed medication. Which of the following actions should the nurse take?

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