A client has been on bed rest for 3 days. Which of the following findings should the nurse identify as an indication that the client is ready to ambulate?

Correct Answer: C

Rationale: In the context of this question, the correct answer is option C) The client can bear weight on both legs. This is the most appropriate indication that the client is ready to ambulate after being on bed rest for 3 days. Weight-bearing on both legs signifies that the client's muscles have retained sufficient strength and function to support ambulation safely. Option A) The client uses a walker to move from the bed to the chair is incorrect because the mere use of a walker does not necessarily indicate readiness to ambulate independently. It may be a precautionary measure even if the client is not fully ready to bear weight on both legs. Option B) The client has a strong cough is unrelated to the client's readiness to ambulate. While coughing is important for respiratory health, it does not directly indicate musculoskeletal readiness for ambulation. Option D) The client has a normal respiratory rate is also not directly related to the client's readiness to ambulate. Although respiratory status is crucial, it does not serve as a primary indicator for ambulation readiness. In an educational context, it is essential for nursing students to understand the criteria for assessing a patient's readiness to ambulate after a period of immobility. This includes evaluating muscle strength, weight-bearing ability, balance, coordination, and overall physical readiness to prevent falls or injuries during ambulation. Understanding these criteria helps nursing students provide safe and effective care to promote patient mobility and independence.

Correct Answer: C

Rationale: In the context of a client requiring a low-sodium diet, the nurse should recommend fresh fruits (Option C) due to their naturally low sodium content. Fresh fruits are typically high in essential nutrients, fiber, and antioxidants without added salt. Option A, pickles, are high in sodium due to the pickling process, making them unsuitable for a low-sodium diet. Canned soup (Option B) often contains high levels of added sodium for preservation and flavor enhancement, making it inappropriate for this client's dietary needs. Smoked salmon (Option D) is also high in sodium as smoking is a method of preservation that typically involves salt. Educationally, understanding the rationale behind food recommendations in specific dietary requirements is crucial for nurses to provide accurate and effective care for their clients. By knowing the sodium content of various food items, nurses can help clients make informed choices to manage their health conditions effectively.

Correct Answer: A

Rationale: In this scenario, the correct answer is option A: "Take your pulse before taking the medication." This instruction is crucial because digoxin is a medication that affects the heart, specifically by slowing the heart rate and increasing the force of contractions. By checking the pulse prior to taking digoxin, the client can monitor for signs of bradycardia (slow heart rate), which is a potential side effect of the medication. This step is essential for ensuring the safety and effectiveness of the drug therapy. Option B, "Take the medication with an antacid," is incorrect because antacids can interfere with the absorption of digoxin, reducing its effectiveness. Mixing digoxin with antacids should be avoided to prevent potential drug interactions. Option C, "Double the dose if you miss one," is incorrect and dangerous advice. Doubling the dose of digoxin can lead to an overdose, which can be life-threatening due to the medication's narrow therapeutic range. Missing a dose should be addressed by taking the missed dose as soon as remembered or skipping it if it is close to the next scheduled dose. Option D, "Take the medication with a high-fiber meal," is also incorrect. While some medications require specific food instructions, taking digoxin with a high-fiber meal is not necessary for its efficacy or safety. In fact, high-fiber meals may delay the absorption of digoxin, affecting its therapeutic effects. Educationally, understanding medication administration and patient education is crucial for nurses. Teaching clients about their medications, including how to take them correctly and what to monitor for, is a fundamental aspect of nursing practice. By providing accurate and clear instructions, nurses can empower clients to manage their medications safely and effectively, promoting positive health outcomes.

Correct Answer: C

Rationale: In assessing a client for dehydration, the nurse should expect dark-colored urine (Option C) as a finding. Dark-colored urine indicates concentrated urine due to decreased fluid intake or dehydration. This is because as the body becomes dehydrated, the kidneys conserve water, leading to more concentrated urine that appears darker. Elevated blood pressure (Option A) is not typically associated with dehydration. Dehydration can actually lead to hypotension due to decreased blood volume. Increased skin turgor (Option B) is a sign of dehydration, but dark-colored urine is a more specific indicator in this context. Bradypnea (Option D), which is slow breathing, is not a common finding in dehydration. Dehydration can lead to increased respiratory rate as the body tries to compensate for the lack of fluids. Educationally, understanding the various signs and symptoms of dehydration is crucial for nurses in providing optimal care to clients. Recognizing these signs early can help prevent complications and guide appropriate interventions to restore fluid balance.

Correct Answer: D

Rationale: In the context of nursing and healthcare, recommending a high-fiber diet is essential for promoting gastrointestinal health, preventing constipation, and supporting overall well-being. Brown rice, the correct answer, is a rich source of dietary fiber, providing essential nutrients and promoting digestive health. It contains both soluble and insoluble fiber, aiding in digestion and promoting satiety, which can be beneficial for clients with various health conditions. On the other hand, the incorrect options, white bread, canned fruit, and cheese, are not ideal choices for a high-fiber diet. White bread is typically processed and lacks the fiber content found in whole grains like brown rice. Canned fruits often have added sugars and lower fiber content compared to fresh fruits. Cheese is a dairy product that does not contain significant amounts of fiber and may be high in saturated fats, which should be limited in certain health conditions. Educationally, understanding the importance of dietary recommendations in nursing care is crucial for promoting patient health and wellness. By selecting the correct high-fiber food like brown rice, healthcare providers can help their clients improve their nutritional intake, manage certain health conditions, and enhance their overall quality of life through appropriate dietary interventions.