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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Vitamin D is often referred to as the "sunshine vitamin" because the body produces it in response to sunlight exposure on the skin. Spending more time indoors reduces sunlight exposure, which can lead to insufficient production of vitamin D in the body. Vitamin D is important for bone health, immune function, and other physiological processes.
B. Vitamin E deficiency is rare in healthy individuals with a balanced diet. It is primarily found in foods such as nuts, seeds, and vegetable oils. Deficiency can occur in conditions where fat absorption is impaired or in certain genetic disorders.
C. There are several B vitamins (e.g., B1, B2, B6, B12) that are essential for various metabolic processes in the body. Deficiencies in specific B vitamins can occur due to inadequate dietary intake, malabsorption
disorders, or other medical conditions. However, preference for indoor activities does not directly correlate with increased risk of vitamin B deficiency.
D. Vitamin A deficiency is more commonly associated with inadequate intake of foods rich in vitamin A (e.g., liver, carrots, sweet potatoes) rather than sunlight exposure. Vitamin A is important for vision, immune function, and cellular growth.
Correct Answer is D
Explanation
D. Before administering a cleansing enema, the client is typically instructed to assume a left-side lying position with the right knee bent. This position helps to facilitate the flow of the enema solution into the colon and allows for better retention of the solution. It also helps to prevent leakage and discomfort during the procedure.

A. Drinking water before administering an enema can help hydrate the client and promote normal bowel function. However, it is not typically a specific instruction related to the administration of the enema itself. Hydration is generally beneficial for bowel health but is not directly related to the enema procedure.
B. After administering the enema solution, the client should be instructed to hold the solution in the bowel for a sufficient amount of time to allow it to soften and loosen stool. The exact duration can vary based on the type and purpose of the enema, but typically, the client is encouraged to retain the solution for a specified period (as instructed by the healthcare provider) before evacuating.
C. This instruction is unrelated to the administration of a cleansing enema. Breathing techniques may be taught for relaxation or to manage discomfort during procedures, but they do not specifically apply to the process of administering an enema.
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