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. Administer the tablet to the client with applesauce: Administering the tablet with a small amount of soft food like applesauce can help facilitate swallowing without altering the integrity of the enteric coating. This method eases the swallowing process while ensuring the medication is delivered properly.

B. Position the client at a 45-degree angle: Clients who have difficulty swallowing should be positioned in an upright 90-degree sitting position, not at 45 degrees, to reduce the risk of aspiration and promote safer swallowing mechanics.

C. Crush the tablet and mix it in pudding for the client: Enteric-coated tablets should never be crushed, as crushing destroys the protective coating designed to prevent the medication from being released in the stomach, potentially causing irritation or reducing drug effectiveness.

D. Instruct the client to tilt their head back when swallowing: Tilting the head back increases the risk of choking and aspiration, especially in clients with swallowing difficulties. It is safer to encourage tucking the chin slightly down when swallowing to help protect the airway.

A. Leg cramps B. Blurred vision C. Urinary frequency D. Gingivitis

Correct Answer is B

Explanation

A. Leg cramps: Leg cramps are a common and expected discomfort during the later stages of pregnancy. They usually result from changes in circulation, pressure from the growing uterus, or altered calcium and magnesium levels.

B. Blurred vision: Blurred vision is a concerning finding in pregnancy as it can be a sign of preeclampsia, a serious hypertensive disorder that poses risks to both the mother and fetus. It requires immediate evaluation by the provider.

C. Urinary frequency: Urinary frequency is a common symptom in late pregnancy due to the pressure of the enlarging uterus on the bladder. It is typically expected unless accompanied by signs of infection.

D. Gingivitis: Gingivitis can occur during pregnancy due to hormonal changes that affect gum tissue. While it should be managed with good oral hygiene, it is not an urgent concern requiring immediate reporting.

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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 administering an enteric-coated medication to an adult client who has right-sided weakness and is having difficulty swallowing tablet. Which of the following actions should the nurse take?

Correct Answer is A

Explanation

A nurse is collecting data from a client who is at 35 weeks of gestation. Which of the following findings should the nurse report to the provider?

Correct Answer is B

Explanation

The nurse has reviewed the Graphic Record and Diagnostic Results at 1030. The nurse is collaborating with another nurse about the client's plan of care. For each potential provider's prescription, click to specify if the potential prescription is anticipated or contraindicated for the client.

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