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. Using a friction-reducing device, such as a slide sheet or transfer sheet, is a recommended method for moving clients with partial assistance needs. The device reduces friction, making it easier and safer to reposition or move the client with minimal physical strain. Two nurses working together with a friction- reducing device can effectively and safely move the client while minimizing the risk of injury for both the client and the nurses.
B. This method is not ideal for moving clients who have limited mobility or who are only partially able to assist. Relying on the client to push with their feet while the nurse lifts can be unsafe and ineffective,
especially if the client’s strength or coordination is compromised.
C. Lifting a client under the shoulders can be uncomfortable and potentially harmful for the client, especially if they have limited mobility or if proper body mechanics are not used. This method also places significant strain on the nurses’ backs and may lead to injury.
D. A trapeze bar can be a helpful aid for clients who have some upper body strength and can assist with repositioning. However, relying solely on one nurse to lift the client’s legs while the client uses the trapeze bar may not provide adequate support for a complete and safe repositioning.

A. "The medication works by decreasing gastric acid secretions." B. "The medication relieves nausea by promoting gastric emptying." C. "The medication relieves nausea by slowing peristalsis." D. "The medication works by relaxing gastric muscles."

Correct Answer is B

Explanation

A. Decreasing gastric acid secretions is not the primary mechanism of action for metoclopramide. This action is more characteristic of medications like proton pump inhibitors (PPIs) or H2 receptor antagonists, which reduce stomach acid to help with conditions such as GERD or peptic ulcers.
B. Promoting gastric emptying is the correct explanation for how metoclopramide relieves nausea. Metoclopramide acts as a prokinetic agent, meaning it enhances gastrointestinal motility by increasing the movement of the stomach and intestines.
C. Slowing peristalsis is not the mechanism of action for metoclopramide. In fact, metoclopramide does the opposite by increasing peristalsis and gastrointestinal motility. Slowing peristalsis would typically exacerbate nausea and lead to delayed gastric emptying, which metoclopramide aims to counteract.
D. Relaxing gastric muscles is not how metoclopramide works. Metoclopramide’s primary action is to increase gastrointestinal motility rather than relaxing the gastric muscles. Other medications, such as antispasmodics, might be used to relax gastrointestinal muscles, but metoclopramide is not used for this purpose.

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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

A nurse is preparing to move a client who is only partially able to assist up in bed. Which of the following methods should the nurse plan to use?

Correct Answer is A

Explanation

A nurse is caring for a client who has nausea and a prescription for metoclopramide intermittent IV bolus every 4 hr as needed. The client asks the nurse how metoclopramide will relieve her nausea. Which of the following explanations should the nurse provide?

Correct Answer is B

Explanation

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