A charge nurse is supervising a newly hired nurse who is instructing a client about how to use a walker. For which of the following actions should the charge nurse intervene?
The client advances the walker and takes a step towards it.
The client takes multiple steps while holding the walker.
The client grasps the walker by the hand grips on the upper bars.
The client lifts the walker as it is moved forward.
The Correct Answer is B
Choice A reason: Advancing the walker and taking a step towards it is the correct technique, ensuring stability by moving the walker first, then stepping. This maintains balance and prevents falls, aligning with safe walker use protocols, so no intervention is needed for this action.
Choice B reason: Taking multiple steps while holding the walker compromises stability, as the walker must be repositioned after each step to ensure support. This increases fall risk, requiring the charge nurse to intervene to correct the technique and ensure the client’s safety during ambulation.
Choice C reason: Grasping the walker by the hand grips on the upper bars is correct, as it provides optimal control and balance. This standard technique supports safe mobility, and no intervention is required, as it adheres to proper walker use guidelines.
Choice D reason: Lifting the walker as it is moved forward is acceptable for lightweight or rolling walkers, depending on the client’s strength and model. While sliding is preferred for standard walkers, lifting is not inherently unsafe, so intervention is unnecessary unless improper execution is observed.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason: Abdominal pain is a hallmark of ectopic pregnancy, where the embryo implants outside the uterus, often in the fallopian tube. Tissue stretching or rupture causes localized pain, driven by tubal irritation or internal bleeding, requiring urgent evaluation to prevent life-threatening hemorrhage in affected clients.
Choice B reason: Hydramnios, excessive amniotic fluid, occurs in intrauterine pregnancies, not ectopic ones, which lack a uterine gestational sac. Ectopic pregnancies cannot produce amniotic fluid, as implantation occurs outside the uterus, making hydramnios an irrelevant finding in this condition’s pathophysiology.
Choice C reason: Profuse vaginal bleeding is uncommon in ectopic pregnancy, which typically causes spotting or mild bleeding. Heavy bleeding suggests miscarriage or other conditions. Ectopic pregnancies cause internal bleeding, leading to abdominal pain, not profuse vaginal hemorrhage, a key diagnostic distinction.
Choice D reason: Elevated blood pressure is not typical in ectopic pregnancy unless complicated by pain-induced stress or shock. Internal bleeding from ectopic rupture often lowers blood pressure due to hypovolemia, making hypertension an unlikely finding compared to the expected abdominal pain presentation.
Correct Answer is C
Explanation
Choice A reason: Touching the inner surface of a sterile drape first contaminates it, as only sterile gloves should contact this area. Outer edges are handled to maintain sterility, so this action violates sterile technique, making it incorrect.
Choice B reason: Placing items within a 1-inch border of the drape is incorrect, as this border is considered non-sterile. Sterile items must be placed centrally to avoid contamination, so this action breaches sterile field principles, making it incorrect.
Choice C reason: Holding sterile instruments above the waist and away from the body maintains sterility, as areas below the waist or close to the body are considered contaminated. This aligns with aseptic technique, making it the correct action for sterile field preparation.
Choice D reason: Pouring solution from 12 inches above risks splashing, contaminating the sterile field. Solutions should be poured from 4-6 inches to control flow and maintain sterility, so this action is incorrect and unsafe for sterile procedures.
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