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 A

Explanation

The correct answer is choice A. 30° lateral.

Choice A rationale:

The 30° lateral position is recommended to reduce pressure on the client’s bony prominences. This position helps distribute the client’s weight more evenly and reduces the risk of pressure injury formation.

Choice B rationale:

The lateral semi-prone recumbent position may not be as effective in reducing pressure on bony prominences as the 30° lateral position. It could potentially increase pressure on certain areas, depending on the client’s body shape and condition.

Choice C rationale:

The supine position can increase pressure on the sacrum and heels, which are common sites for pressure injuries. Therefore, it is not the best position for a client at risk for pressure injury formation.

Choice D rationale:

The 45° supported Fowler’s position can increase pressure on the sacrum and ischial tuberosities, another common site for pressure injuries. Therefore, it is not the most effective position for reducing pressure on bony prominences for a client at risk for pressure injury formation.

A. Justice. B. Veracity. C. Fidelity. D. Autonomy.

Correct Answer is D

Explanation

Choice A rationale:

Justice refers to the fair distribution of resources and benefits. It pertains to treating individuals equitably and ensuring that their rights are respected. However, in this scenario, the nurse is specifically addressing the client's right to refuse treatment, which aligns more with the concept of autonomy.

Choice B rationale:

Veracity is the principle of truthfulness and honesty in communication between healthcare professionals and clients. While it is an important ethical principle, it does not directly relate to the client's right to refuse treatment. This right falls under the principle of autonomy, where individuals have the right to make decisions about their own healthcare, including the decision to refuse treatment.

Choice C rationale:

Fidelity, also known as loyalty or faithfulness, refers to the nurse's commitment to keeping promises and being dedicated to the well-being of the client. While respecting the client's autonomy is part of being faithful to their needs and preferences, the specific right to refuse treatment is better categorized under the principle of autonomy.

Choice D rationale:

Autonomy is the correct choice. Autonomy emphasizes an individual's right to make decisions regarding their own healthcare based on their values, beliefs, and preferences. In this context, the nurse's responsibility is to uphold the client's autonomy by respecting their decision to refuse treatment. The nurse should ensure that the client has been properly informed about the risks and benefits of the treatment and that their decision is voluntary and informed.

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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 caring for a client who is at risk for pressure injury formation due to immobility. The nurse should place the client in which of the following positions to reduce pressure on the client's bony prominences?

Correct Answer is A

Explanation

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Correct Answer is D

Explanation

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