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 A

Explanation

A. Before administering an enteral feeding, it's important to discard any residual gastric contents to prevent aspiration. Aspirating and discarding the residual helps to assess gastric emptying and ensure that the stomach is able to tolerate the feeding.
B. While placing the client in a semi-Fowler's position is generally recommended during and after enteral feedings to help prevent aspiration, it's not necessary prior to administering the feeding.
C. Warming the feeding solution to body temperature can help to improve the client's comfort and may reduce nausea. However, it's not a critical step before administering the feeding.
D. Testing the pH of gastric aspirate is important to assess for gastric placement and to ensure that the tube is not in the lungs. However, it's typically done prior to the initial placement of the NG tube and is not routinely repeated before each feeding.

A. Ibuprofen B. Omeprazole C. Senna D. Zolpidem

Correct Answer is C

Explanation

A. Ibuprofen is a nonsteroidal anti-inflammatory drug (NSAID) used to reduce pain and inflammation. While it does not directly affect bowel obstruction, NSAIDs can cause gastrointestinal irritation and potentially worsen symptoms in some patients. However, it is not the primary medication to withhold due to a small bowel obstruction.
B. Omeprazole is a proton pump inhibitor (PPI) that reduces stomach acid. It is generally safe to use in the context of a small bowel obstruction because it does not affect bowel motility directly. It might be used to manage symptoms related to acid reflux or gastritis, which could be secondary issues in a patient with SBO.
C. Senna is a stimulant laxative used to promote bowel movements. In the context of a small bowel obstruction, administering a laxative like Senna is contraindicated because it can worsen the obstruction by increasing bowel motility or causing further distention. The primary goal in treating an SBO is to relieve the obstruction, and using a laxative could complicate the situation.
D. Zolpidem is a sedative-hypnotic used for short-term management of insomnia. It does not directly impact bowel function or obstruction. While not ideal for all patients, it does not specifically exacerbate a small bowel obstruction.

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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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Naxlex Comprehensive Predictor Exams

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