Aug.12 NCLEX Daily Practice Questions

August 12, 2024

Monday

 

1 / 1

A legally blind client is being prepared to ambulate 1 day after an appendectomy. What is the most appropriate action by the nurse?

Arrange for the client's service dog to come to the health care facility as soon as possible

Describe the environment in detail so the client can ambulate safely with a cane

Instruct the unlicensed assistive personnel to walk beside the client and lead by the hand

Walk slightly ahead of the client with the client's hand resting on the nurse's elbow

On the first postoperative day, the nurse assists the client with

• Ambulation to evaluate alertness,
• Pain level,
• Signs of orthostatic hypotension,
• Problems with gait or mobility, and
• Ability to ambulate safely.

The nurse also considers pre-existing limitations to ambulation such as the use of assistive aids (eg, sighted guides, canes, guide dogs). Clients who used any ambulatory assistive aids before surgery require postoperative evaluation prior to ambulatory independence. When walking with a client who is legally blind, the nurse uses the sighted-guide technique by walking slightly ahead of the client with the client holding the nurse's elbow. The nurse should describe the environment while ambulating the client.

(Option 1) The service dog may be brought to the hospital to assist in ambulation once the nurse has determined the client can ambulate safely.

(Option 2) After evaluation by the nurse, the client may be allowed to use a cane to ambulate around the nursing unit.

(Option 3) Instructing the unlicensed assistive personnel to ambulate the client is an inappropriate assignment for a client who is 1 day postoperative and legally blind. Nursing assessment is required to determine if the client is able to ambulate safely.

Educational objective: When ambulating a client who is legally blind, the nurse uses the sighted-guide technique by walking slightly ahead with the client holding the nurse's elbow.

On the first postoperative day, the nurse assists the client with

• Ambulation to evaluate alertness,
• Pain level,
• Signs of orthostatic hypotension,
• Problems with gait or mobility, and
• Ability to ambulate safely.

The nurse also considers pre-existing limitations to ambulation such as the use of assistive aids (eg, sighted guides, canes, guide dogs). Clients who used any ambulatory assistive aids before surgery require postoperative evaluation prior to ambulatory independence. When walking with a client who is legally blind, the nurse uses the sighted-guide technique by walking slightly ahead of the client with the client holding the nurse's elbow. The nurse should describe the environment while ambulating the client.

(Option 1) The service dog may be brought to the hospital to assist in ambulation once the nurse has determined the client can ambulate safely.

(Option 2) After evaluation by the nurse, the client may be allowed to use a cane to ambulate around the nursing unit.

(Option 3) Instructing the unlicensed assistive personnel to ambulate the client is an inappropriate assignment for a client who is 1 day postoperative and legally blind. Nursing assessment is required to determine if the client is able to ambulate safely.

Educational objective: When ambulating a client who is legally blind, the nurse uses the sighted-guide technique by walking slightly ahead with the client holding the nurse's elbow.

Your score is

The average score is 100%

0%

Restart quiz

Pass NCLEX with US 

Aug.12 NCLEX Daily Practice Questions

Aug.12 NCLEX Daily Practice Questions

Aug.12 NCLEX Daily Practice Questions