A nurse is preparing a client for ambulation. Which of the following actions should the nurse take to determine the client's level of strength?

Palpate the client's pedal pulses.

Ask the client how strong she feels today.

Ask the client to touch her finger to her nose.

Ask the client to push her feet against the nurse's palms.

Answer and Explanation

The Correct Answer is D

A.   Palpating the pedal pulses is important for assessing circulation and vascular status, not for evaluating muscle strength. This action helps in determining blood flow to the lower extremities but does not provide information about the client’s muscle strength or ability to ambulate.
B.   Asking the client how strong she feels provides subjective information about her perceived strength but does not objectively assess muscle strength. This method relies on the client's self-assessment, which may not always be accurate or reliable.
C.   Touching the finger to the nose is a test of coordination and can help assess motor function and neurological status. While it provides information about coordination, it does not specifically measure the client’s overall muscle strength, especially in the lower extremities, which is critical for safe ambulation.
D.   Asking the client to push her feet against the nurse’s palms is an effective way to assess lower
extremity muscle strength. This action allows the nurse to gauge the client’s ability to exert force with
their legs, which is essential for ambulation and overall mobility.

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Correct Answer is D

Explanation

A. Crutches should not be used to support body weight under the arms, as this can cause nerve damage or discomfort. Instead, weight should be supported on the hands and arms, with the crutches positioned to support the client’s weight. Proper use involves placing the crutches slightly in front of the feet, with weight supported on the hands, not the underarms.
B. While it's important to be aware of your surroundings, looking down at your feet can be counterproductive as it may affect balance and coordination. The client should maintain an upright posture and look ahead to ensure proper gait and balance while moving. This helps in coordinating the movement of crutches and feet more effectively.
C. In a four-point gait, each crutch and foot move alternately, which is different from the three-point gait. The three-point gait involves moving both crutches and the affected leg forward simultaneously, followed by the unaffected leg.
D. In the three-point gait, the client moves both crutches forward at the same time while keeping the affected leg off the ground or in a non-weight-bearing position. Then, the client swings the unaffected leg forward to step past the crutches. This method ensures that weight is only placed on the unaffected leg while moving.

A. Lactated Ringer's solution B. Dextrose 10% in water C. Dextrose 5% in water D. 0.9% sodium chloride

Correct Answer is C

Explanation

A. While Lactated Ringer's is often used for fluid resuscitation, it doesn't contain the necessary nutrients to replace TPN. It can lead to electrolyte imbalances and other complications if used for extended periods.
B. While Dextrose 10% provides calories, it lacks essential amino acids, electrolytes, and other nutrients found in TPN. Prolonged use can lead to imbalances and nutritional deficiencies.
C. Dextrose 5% in water is a commonly used IV fluid that can be administered temporarily while waiting for the next TPN container. It provides hydration and some calories, but it's important to monitor the client's glucose levels closely.
D. While 0.9% sodium chloride (normal saline) is used for fluid replacement, it can lead to hypernatremia (excess sodium) if used for extended periods, especially in clients receiving TPN.

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A nurse is preparing a client for ambulation. Which of the following actions should the nurse take to determine the client's level of strength?

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