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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale:
Inquiring whether the client's family knows about their anxiety is not directly related to addressing the client's current anxiety. The focus should be on the client's feelings and needs rather than involving the family in this particular instance.
Choice B rationale:
This choice is the most appropriate response. Asking the client to share memories from their past redirects their attention from the current anxiety-provoking situation. Discussing positive memories can help alleviate anxiety and provide comfort to the client.
Choice C rationale:
Suggesting to talk later after caring for other clients dismisses the client's immediate need for support and comfort. It's essential to address the client's anxiety promptly rather than delaying the discussion.
Choice D rationale:
Asking the client why they are feeling anxious might put them on the spot and could potentially escalate their anxiety. Instead of prompting them to explain the cause of their anxiety, the nurse should focus on providing reassurance and distraction.
Correct Answer is A
Explanation
Choice A rationale:
Providing oral replacement solution is the nurse's priority in this situation. Diarrhea can lead to dehydration and electrolyte imbalances due to fluid loss. Oral rehydration solutions contain electrolytes and fluids that can help restore the body's hydration balance. Ensuring the client's adequate fluid intake takes precedence in preventing complications associated with diarrhea.
Choice B rationale:
Obtaining a prescription for antidiarrheal medication is important, but it is not the priority action. The client's dehydration and electrolyte imbalance should be addressed first through oral rehydration before focusing on symptom management.
Choice C rationale:
Offering the client a sitz bath is not the priority action for someone experiencing diarrhea. Sitz baths are typically used for conditions affecting the perineal area, such as hemorrhoids or perineal discomfort. However, in the case of diarrhea, the primary concern is managing fluid and electrolyte balance.
Choice D rationale:
Collecting a specimen of the client's stool is important for diagnostic purposes, but it is not the immediate priority. The client's hydration status and electrolyte balance should be addressed promptly to prevent complications. Stool collection can be considered once the client's hydration has been stabilized.
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