A nurse is caring for the client who has Ménière's disease and asks if he is allowed to ambulate independently. Which of the following responses should the nurse make?

"Yes, you are free to move around as you wish."

"We will have to get a prescription from your provider.

"No, you are on strict bedrest and must not be up."

"Please ring for assistance when you wish to get out of bed."

Answer and Explanation

The Correct Answer is D

A. Allowing free movement could increase the risk of falls due to dizziness.
B. While involving the provider is important, immediate safety measures should be communicated directly.
C. Strict bedrest is not typically necessary, and movement can help prevent complications like blood clots.
D. Assisting the client when they wish to get out of bed ensures safety by preventing falls, which are a significant risk for those with Ménière's disease due to vertigo.

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Correct Answer is C

Explanation

A. A client with a hemi-colectomy and colostomy is not at highest risk for aspiration.
B. A client with a chest tube may have respiratory issues but is not at the highest risk for aspiration.
C. A client receiving continuous enteral feeding through an NG tube is at the highest risk for aspiration due to the risk of feeding contents entering the airway.
D. A client with Crohn's disease and an ileostomy is not at the highest risk for aspiration.

A. Positions the wrapped package on the bedside table so the outer flap is away from her. B. Holds gauze packages 15 cm (6 in) above the sterile field. C. Holds a bottle of solution with the label away from the palm of the hand. D. Wears sterile gloves when moving sterile items on the sterile field.

Correct Answer is C

Explanation

A. Positions the wrapped package on the bedside table so the outer flap is away from her: This action is correct because opening the flap away from the body minimizes the risk of contaminating the sterile field.

B. Holds gauze packages 15 cm (6 in) above the sterile field: This action is correct. Dropping sterile items from a height of 6 inches or more prevents contamination by ensuring they do not touch the edges or outside surfaces of the sterile field.

C. Holds a bottle of solution with the label away from the palm of the hand: When pouring a solution, the label should be held toward the palm of the hand to protect it from damage caused by spills. A damaged label could make it difficult to identify the solution, increasing the risk of error.

D. Wears sterile gloves when moving sterile items on the sterile field: This action is appropriate. Sterile gloves help maintain the sterility of the field and are required when manipulating sterile items.

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A nurse is caring for the client who has Ménière's disease and asks if he is allowed to ambulate independently. Which of the following responses should the nurse make?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Explanation

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