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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Correct Answer is C

Explanation

Choice A rationale:

Metabolic acidosis is not the correct acid-base imbalance for the given ABG results. Metabolic acidosis is characterized by a low pH (acidic), low bicarbonate (HCO3) levels, and a compensatory decrease in the PaCO2. In the provided ABG results, the pH is elevated, and both the PaCO2 and HCO3 levels are within normal ranges.

Choice B rationale:

Respiratory acidosis is also not the correct acid-base imbalance for the given ABG results. Respiratory acidosis occurs when there is an elevation in PaCO2 due to inadequate ventilation, leading to an acidic pH. In the provided ABG results, the pH is elevated, and the PaCO2 level is within normal range.

Choice C rationale:

Metabolic alkalosis is the correct acid-base imbalance for the given ABG results. Metabolic alkalosis is characterized by an elevated pH, elevated bicarbonate (HCO3) levels, and a compensatory increase in PaCO2. In this case, the pH is higher than the normal range, the HCO3 level is elevated, and the PaCO2 is also slightly increased as the body attempts to compensate.

Choice D rationale:

Respiratory alkalosis is not the correct answer based on the provided ABG results. Respiratory alkalosis is marked by an elevated pH and a decrease in PaCO2 due to excessive ventilation. In the given ABG results, the pH is elevated, but the PaCO2 is not decreased; it's within the normal range.

A. Schedule the client as the last surgery of the day. B. Notify ancillary departments of the client's allergy. C. Label the surgical suite as latex-free. D. Provide powdered gloves for the staff's use. E. Ensure a latex allergy cart is available.

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

Explanation

Choice A rationale:

Scheduling the client as the last surgery of the day is not directly related to the client's latex allergy. It might not be feasible to always schedule the client last, and this action does not specifically address the client's needs related to latex exposure.

Choice B rationale:

Notifying ancillary departments of the client's latex allergy is an important step to ensure the client's safety during the surgical process. This action helps other departments prepare and prevent accidental latex exposure, which could trigger an allergic reaction in the client.

Choice C rationale:

Labeling the surgical suite as latex-free is crucial to preventing latex exposure during the surgery. It alerts all staff members entering the surgical suite about the presence of a latex-allergic patient and reminds them to take appropriate precautions.

Choice D rationale:

Providing powdered gloves for the staff's use is not recommended, as powdered gloves can actually carry latex proteins and increase the risk of latex exposure. Powdered gloves have been associated with allergic reactions, so it's important to avoid their use in a latex-sensitive environment.

Choice E rationale:

Ensuring a latex allergy cart is available is a proactive measure to have necessary equipment and supplies on hand in case of an allergic reaction. This cart would contain latex-free items and medications that can be used to manage an allergic reaction should it occur during or after surgery.

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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 reviewing the ABG results for a client. The client's results are pH 7.47, PaCO2 30 mm Hg, HCO3 25 mEq/L, and SaO2 90%. The nurse should identify that the client is experiencing which of the following acid-base imbalances?

Correct Answer is C

Explanation

A nurse is completing a preadmission interview for a client who is to undergo surgery the following day. The client reports a latex allergy. Which of the following interventions should the nurse include when planning care for the client's surgery? (Select all that apply)

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

Explanation

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