A nurse is collecting data on the mobility of a client. Which of the following actions should the nurse take first?

Ask the client to stand for 5 seconds.

Ask the client to place their feet on the floor.

Ask the client to sit on the edge of the bed for 2 min.

Ask the client to march in place.

Answer and Explanation

The Correct Answer is C

A)   Standing requires more mobility and strength; it's not the first step in assessing mobility.
B)   Placing feet on the floor assesses the client's ability to follow instructions and indicates readiness for further mobility assessments but is not the first step compared to sitting on the edge of the bed for 2 minutes.
C)   This is the first action that the nurse should take to assess the client's mobility and balance. Sitting on the edge of the bed for 2 min allows the nurse to observe the client's posture, strength, coordination, and ability to maintain equilibrium.
D)   This is a more advanced mobility assessment and should come after basic assessments like placing feet on the floor.

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Correct Answer is C

Explanation

A. Minimal assist means that the client needs some verbal cues or light touch to perform an activity.
B. Moderate assist means that the client needs physical assistance from one person to perform an activity.
C. The client's ability to rise from a seated position using a cane for support indicates that they require no assistance from the nurse or another person to perform this activity. Therefore, the appropriate activity level assignment is "No assist."
D. Maximum assist means that the client needs physical assistance from two or more people to perform an activity.

A. A client who has pneumonia after being on a ventilator B. A client who has a bladder infection and has an indwelling urinary catheter C. A client who has a surgical site infection D. A client who has influenza acquired from a coworker E. A client who has an infection at their central line insertion site

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

Explanation

A) HAIs, are infections that clients acquire while receiving health care services in any setting, such as hospitals, clinics, or home care agencies. Ventilator-associated pneumonia is a common HAI.
B) Catheter-associated urinary tract infections are a common HAI.

C) Surgical site infections are a common HAI.

D) A client who has influenza acquired from a coworker is not an example of an HAI, because the infection was not related to the health care services they received.
E) Central line-associated bloodstream infections are a common HAI.

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A nurse is collecting data on the mobility of a client. Which of the following actions should the nurse take first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assisting in performing a mobility assessment on a client. The client can rise from a seated position using a cane for support. The nurse should assign the client which of the following activity levels?

Correct Answer is C

Explanation

A nurse is reinforcing teaching with a newly licensed nurse about health care-associated infections (HAIs). Which of the following examples should the nurse include as examples of HAIS?

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

Explanation

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