A nurse is getting a client out of bed to ambulate for the first time.

The client is pale, diaphoretic, has a pulse of 100/minute, and says, “I feel weak.

Let me sit on the side of the bed for a minute.” What finding should the nurse document?

A normal reaction to a position change.

Gait belt applied.

Orthostatic hypotension noted with dangling.

Elevated blood sugar probable.

Answer and Explanation

The Correct Answer is C

Orthostatic hypotension noted with dangling.

This means that the client’s blood pressure drops when changing position from lying down to sitting or standing. This can cause symptoms such as paleness, sweating, rapid pulse, weakness, and dizziness.

The nurse should document this finding and report it to the physician.

Choice A is wrong because a normal reaction to a position change would not cause such severe symptoms.

Choice B is wrong because the gait belt applied is not a finding but an intervention.

Choice D is wrong because elevated blood sugar probable is not a finding but a speculation.

Choice E is wrong because spot accucheck obtained is not a finding but an action.

Choice F is wrong because fear of falling expressed by a client is not a finding related to the client’s vital signs or physical condition.

Choice G is wrong because provided reassurance is not a finding but a nursing measure.

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Correct Answer is D

Explanation

The needle gauge size for subcutaneous injections should be between 25 and 31, depending on the patient’s size and the viscosity of the medication.

A smaller gauge number means a larger diameter needle, which can cause more pain and tissue damage.

Choice A is wrong because 8 is too large for subcutaneous injections and can cause bleeding and bruising.

Choice B is wrong because 20 is also too large for subcutaneous injections and can cause similar complications as choice A.

Choice C is wrong because 21 is still too large for subcutaneous injections and can cause discomfort and injury to the patient.

The needle length for subcutaneous injections should be between ½ inch and ⅝ inch, depending on the amount of subcutaneous tissue present. The nurse should pinch the skin and insert the needle at a 45-degree angle to ensure proper delivery of the medication.

A. Continue to observe the client. B. Ask the client to describe the discomfort. C. Encourage the client to progressively relax all muscle groups. D. Administer the prescribed analgesic and document the client’s response.

Correct Answer is B

Explanation

Ask the client to describe the discomfort. This is the best action to establish a nursing diagnosis of pain related to an abdominal incision because it allows the nurse to assess the location, intensity, quality, and duration of the pain, as well as any factors that aggravate or relieve it.

This information can help the nurse to plan appropriate interventions and evaluate their effectiveness.

Choice A. Continue to observe the client is wrong because it does not address the client’s pain or communicate empathy. The nurse should not ignore or minimize the client’s pain, but rather acknowledge it and offer assistance.

Choice C. Encourage the client to progressively relax all muscle groups is wrong because it is a nonpharmacological intervention that may help to reduce pain, but it does not establish a nursing diagnosis of pain. The nurse should first assess the client’s pain before implementing any interventions.

Choice D. Administer the prescribed analgesic and document the client’s response is wrong because it is a pharmacological intervention that may help to relieve pain, but it does not establish a nursing diagnosis of pain. The nurse should first assess the client’s pain before administering any medications.

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A nurse is getting a client out of bed to ambulate for the first time. The client is pale, diaphoretic, has a pulse of 100/minute, and says, “I feel weak. Let me sit on the side of the bed for a minute.” What finding should the nurse document?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Which needle gauge should a nurse select when administering a medication subcutaneously?

Correct Answer is D

Explanation

For a client who is crying and seems agitated after major abdominal surgery, which action should a nurse take to establish a nursing diagnosis of pain related to an abdominal incision?

Correct Answer is B

Explanation

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A nurse is getting a client out of bed to ambulate for the first time.

The client is pale, diaphoretic, has a pulse of 100/minute, and says, “I feel weak.

Let me sit on the side of the bed for a minute.” What finding should the nurse document?