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 C

Explanation

A. The client may have difficulty voiding despite being taken to the bathroom, especially if there is an underlying issue such as urinary retention or an obstruction. Therefore, this step is usually taken after assessing the situation further.
B. Inserting a straight catheter is an invasive procedure that should not be the initial action. It is typically done after other non-invasive measures have been taken to evaluate the reason for the lack of voiding. Straight catheterization can be considered if other methods do not resolve the issue or if there is a clear indication of urinary retention that needs immediate intervention.
C. Performing a bladder scan is the appropriate first step. A bladder scan, or portable ultrasound, helps assess the amount of urine in the bladder and determines if the client is retaining urine. This non- invasive procedure can provide valuable information about the presence of urinary retention, which guides further intervention.
D. Increasing fluid intake might be appropriate if the client is dehydrated or has not been drinking enough fluids. However, this step is not the first action to take if the client has not voided for 8 hours. The priority is to determine if there is a physiological issue, such as urinary retention, before increasing fluids.

A. One cup of pureed avocado B. One cup of lentils C. One cup of brown rice D. One cup of orange juice

Correct Answer is B

Explanation

A. This option is not the best source of protein. While avocados are nutritious and contain healthy fats, they are low in protein. One cup of pureed avocado contains approximately 3 grams of protein, which is relatively low compared to other protein-rich foods. It’s better for providing healthy fats rather than substantial protein needed for wound healing.
B. This is the best source of protein among the choices. Lentils are an excellent source of plant-based protein, providing about 18 grams of protein per cup. They are also rich in fiber, vitamins, and minerals. For someone on a vegan diet, lentils can effectively support protein needs essential for wound healing and overall recovery.
C. This option is not the best source of protein. Brown rice is a good source of carbohydrates and provides about 5 grams of protein per cup, but it is not as protein-dense as lentils. While brown rice can be part of a balanced diet, it does not provide as much protein as lentils or other high-protein vegan foods.
D. This option does not provide significant protein. Orange juice is rich in vitamin C, which is important for wound healing, but it contains negligible protein. It's not a protein source and should not be relied upon for meeting protein needs.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is C

Explanation

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Correct Answer is B

Explanation

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