A nurse is planning to assist a client who has left-sided weakness to ambulate using a gait belt. Which of the following actions should the nurse plan to take?

Walk on the client's right side.

Instruct the client to look down at their feet when ambulating.

Have the client sit on the side of the bed for at least 60 seconds before ambulating.

Place the gait belt securely around the client's lower chest.

Answer and Explanation

The Correct Answer is C

The correct answer is C.

Choice A reason: Walking on the client’s right side is incorrect because the nurse should walk on the client’s left side. This is the weaker side and the side where support is most needed.

Choice B reason: Instructing the client to look down at their feet when ambulating is incorrect because the client should be instructed to look straight ahead, not down at their feet, to maintain balance and prevent falls.

Choice C reason: Have the client sit on the side of the bed for at least 60 seconds before ambulating. This allows the nurse to assess the client’s tolerance and readiness for ambulation, and it helps prevent dizziness or fainting due to orthostatic hypotension.

Choice D reason: Placing the gait belt securely around the client’s lower chest is incorrect because the gait belt should be placed around the client’s waist, not the lower chest. This provides a secure grip for the nurse and allows for safer ambulation.

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Free Nursing Study Resources

Correct Answer is D

Explanation

The correct answer is choice d. When removing a peripheral IV catheter, the nurse uses scissors to remove the tape that secures the catheter.

Choice A rationale:

Inserting the tip of the enema tube 8 cm (3.1 in) is within the recommended range for adults, which is typically 7.5 to 10 cm (3 to 4 in). This action does not require intervention.

Choice B rationale:

Elevating the head of the bed when caring for a client’s body after death is a standard practice to prevent discoloration of the face and to facilitate drainage. This action does not require intervention.

Choice C rationale:

Using a clean washcloth, soap, and water for indwelling catheter care is appropriate and follows infection control guidelines. This action does not require intervention.

Choice D rationale:

Using scissors to remove the tape that secures a peripheral IV catheter is unsafe as it poses a risk of cutting the catheter or the client’s skin. This action requires intervention to ensure the nurse uses a safer method, such as using adhesive remover or gently peeling the tape away by hand.

A. Measure the amount of aspirate in the NG tube. B. Flush the tube with 50 mL of tap water. C. Examine the color of aspirated secretions. D. Measure the pH of the client's aspirate. E. Obtain an x-ray of the client's chest and abdomen.

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

Explanation

Choice A rationale:

Measuring the amount of aspirate in the NG tube is one way to verify the placement of the tube. Aspirate should be tested for color, pH, and other characteristics to ensure proper positioning.

Choice B rationale:

Flushing the tube with tap water doesn't directly verify tube placement. This action might inadvertently introduce air into the tube, potentially leading to inaccurate assessment results.

Choice C rationale:

Examining the color of aspirated secretions is an essential step in verifying tube placement. Different colors of aspirate can indicate different anatomical locations, helping to ensure the tube is properly positioned.

Choice D rationale:

Measuring the pH of the client's aspirate is another important method to verify NG tube placement. Gastric aspirate tends to be acidic, while respiratory aspirate is usually more alkaline.

Choice E rationale:

Obtaining an x-ray of the client's chest and abdomen is a definitive method for confirming NG tube placement. It provides direct visualization of the tube's location and ensures accuracy.

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A nurse is planning to assist a client who has left-sided weakness to ambulate using a gait belt. Which of the following actions should the nurse plan to take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is observing a newly licensed nurse provide client care. Which of the following actions by the newly licensed nurse requires intervention by the nurse?

Correct Answer is D

Explanation

A nurse is inserting an NG tube for a client who has a new prescription for enteral feedings. Which of the following actions should the nurse take to verify the placement of the client's tube? (Select all that apply.).

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

Explanation

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