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. While holding the client’s arm might seem like a supportive action, it is not the most effective method to prevent a fall. If a client begins to fall, holding their arm could result in injury to either the client or the nurse, as it does not provide adequate control to prevent the fall. Instead, more proactive measures should be taken to safely manage the situation.
B. Assuming a narrow base of support (standing with feet close together) is actually less stable and can increase the risk of falling. To effectively prevent or manage a fall, the nurse should assume a wide base of support (feet apart) to enhance stability and balance.
C. If a fall is imminent and cannot be prevented, the best approach is to safely lower the client to the floor to minimize the risk of injury. The nurse should support the client’s body as they go down, guiding them gently to the floor to avoid a sudden impact. This technique helps reduce the potential for serious injuries such as fractures or head trauma.
D. Leaning the client toward the wall might provide temporary support but does not fully address the risk of a fall. It may also place the client in an awkward or unsafe position. The best approach is to take more direct action to prevent the fall or safely lower the client if the fall is unavoidable.

A. To remove gastric acid that might cause dyspepsia B. To identify delayed gastric emptying C. To determine the client's electrolyte balance D. To confirm the placement of the NG tube

Correct Answer is B

Explanation

A. Measuring gastric residuals is not intended to remove gastric acid or address dyspepsia (indigestion). Instead, residuals help assess the function of the stomach and the effectiveness of the feeding process.
B. Measuring gastric residuals helps determine if the stomach is emptying properly. If residuals are high, it can indicate delayed gastric emptying, which means the stomach is not processing the enteral feedings effectively. This could signal potential issues like gastroparesis or obstruction and may necessitate adjusting the feeding rate or formula, or evaluating the client for other complications.
C. While electrolyte balance is important in overall nutritional care, measuring gastric residuals is not used to assess electrolytes. Instead, it focuses on stomach function and gastric emptying.
D. Confirming the placement of the NG tube is done through other methods, such as aspirating gastric contents and checking pH, or by using imaging techniques. Measuring residuals does not provide information on tube placement but rather on stomach function and feeding tolerance.

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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

A nurse is assisting a client during ambulation when the client begins to fall. Which of the following actions should the nurse take?

Correct Answer is C

Explanation

A nurse is caring for a client who receives intermittent enteral feedings through an NG tube. Before administering a feeding, the nurse should measure the gastric residual for which of the following purposes?

Correct Answer is B

Explanation

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