The nurse will be assisting the client to walk. What should the nurse do first?

Assist the client to a sitting position at the side of the bed

Determine the client's strength, coordination, and activity tolerance

Help the client into a standing position

Ask another nurse for assistance

Answer and Explanation

The Correct Answer is B

B. Such an assessment helps in determining the level of assistance the client will need and ensures the safety of both the client and the nurse.

A. Helping the client to sit at the edge of the bed allows them to acclimate to being upright, assess their readiness to stand, and ensures their safety before attempting to walk. However, it is not the priority.

C. After assisting the client to a sitting position at the edge of the bed and assessing their readiness, the nurse can proceed to help the client into a standing position. However, it is not the priority.

D. This option may be necessary if the client requires two-person assistance due to their condition, mobility status, or safety concerns. However, asking for assistance typically comes after assessing the client's readiness and ensuring they are positioned correctly for ambulation.

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Correct Answer is B

Explanation

B. Heard over most of the lung fields, except for the major bronchi and the trachea.

Low intensity and pitch, with a longer inspiratory phase than expiratory phase. They are softer and more breezy in quality. Vesicular breath sounds are heard over the peripheral lung fields, including the apex (top) of the lungs.

A. Heard over the major bronchi, which are near the sternum and between the scapulae. They are of intermediate intensity and pitch, with equal inspiration and expiration phases. They are typically heard in the 1st and 2nd intercostal spaces along the sternal border and between the scapulae.

C. Heard over the trachea and larynx.

Characteristics: High intensity and pitch, with a short inspiratory phase and a longer expiratory phase. They are louder and harsher in quality, resembling the sound of air blowing through a hollow pipe.

D. Crackles are abnormal breath sounds that can be fine or coarse.

Fine crackles are high-pitched, short, popping sounds heard during inspiration, often due to fluid in the small airways or alveoli.

Coarse crackles are loud, low-pitched, bubbling sounds heard during inspiration, typically due to the presence of secretions in the larger airways.

A. listens as the client describes the day she was diagnosed with breast cancer. B. compliments the client when he correctly places an ostomy bag on his stoma. C. provides a bed bath with a back rub to help the client relax. D. maintains eye contact with the client throughout their conversation.

Correct Answer is A

Explanation

A. By actively listening, the nurse shows empathy and a willingness to understand the client's perspective. Understanding significant events like a cancer diagnosis can help the nurse better anticipate the client's emotional and psychological needs.

B. This action shows support and encouragement for the client's achievements in managing their condition. It demonstrates the nurse's awareness of the client's efforts and competence in self-care. While it is positive reinforcement and supportive, it focuses more on the client's physical abilities rather than a deeper understanding of their personal experiences or emotions.

C. This action shows attentiveness to the client's physical comfort and emotional well-being. Offering a back rub during a bed bath can be soothing and comforting, addressing both physical and emotional needs. It demonstrates a caring approach to providing care that considers the client's comfort and relaxation.

D. Eye contact is an important non-verbal communication skill that conveys attentiveness and respect. It helps establish a connection and rapport between the nurse and the client. While maintaining eye contact is important for effective communication and building trust, it alone does not necessarily illustrate knowing the client in terms of understanding their personal experiences or emotions.

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The nurse will be assisting the client to walk. What should the nurse do first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

When auscultating over the apex of the client's lung field, what breath sound should the nurse expect to hear?

Correct Answer is B

Explanation

Which example best illustrates the principle of the nurse "knowing" the client? The nurse:

Correct Answer is A

Explanation

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