A nurse at an extended-care facility is instructing a class of assistive personnel (AP) about the use of assistive devices during client ambulation.
Which of the following instructions should the nurse include about assisting clients who use a cane?

“The client should first move the strong leg then the weak one.”.

“When the client moves, he should move the cane forward first.”.

“The client should hold the cane on the weak side of his body.”.

“The grip should be level with the client’s waist.”. .

Answer and Explanation

The Correct Answer is B

Choice A rationale

The statement “The client should first move the strong leg then the weak one” is not the best practice when using a cane. The client should move the cane and the weak leg forward at the same time, then move the strong leg.
Choice B rationale
The statement “When the client moves, he should move the cane forward first” is the correct practice. Moving the cane first provides stability and support for the next step.
Choice C rationale
The statement “The client should hold the cane on the weak side of his body” is not the correct practice. The cane should be held on the strong side of the body to provide support for the weak side.
Choice D rationale
The statement “The grip should be level with the client’s waist” is a good practice, but it’s not the best answer for this question. The grip of the cane should be at the level of the client’s wrist when the client’s arm is hanging down. This allows the client to maintain a slight bend in their elbow when holding the cane.

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Correct Answer is C

Explanation

Choice A rationale
Placing a 1-inch needle on the syringe is not appropriate for an intradermal injection such as a tuberculin skin test. Intradermal injections require a much shorter needle, typically 1/4 to 1/2 inch in length.
Choice B rationale
Holding the syringe at a 20° angle to the client’s skin is not correct for an intradermal injection. For an intradermal injection, the syringe should be held at a much shallower angle, typically about 5 to 15 degrees.
Choice C rationale

Drawing up 0.1 mL of purified protein derivative (PPD) from the vial is the correct action when preparing to administer a tuberculin skin test. This is the standard amount of PPD used for a tuberculin skin test.
Choice D rationale
Pinching the skin at the chosen site with the non-dominant hand before inserting the needle is not typically done for an intradermal injection. Instead, the skin is usually stretched taut to provide a flat surface for the injection.

A. “I will place a bath seat in my shower to use when I bathe.”. B. “I will keep the fluorescent ceiling light on in my room at night.”. C. “I will place an area rug at the entry of my bathroom.”. D. “I will keep my walker at the end of my bed.”. .

Correct Answer is A

Explanation

Choice A rationale
Placing a bath seat in the shower is a good safety measure for a patient with a history of falls. It allows the patient to sit while bathing, reducing the risk of slipping and falling.
Choice B rationale

Keeping the fluorescent ceiling light on in the room at night can actually increase the risk of falls. It can create shadows and glare that can be disorienting, especially for older adults.
Choice C rationale
Placing an area rug at the entry of the bathroom is not recommended. Rugs can easily become tripping hazards, especially if they’re not secured to the floor.
Choice D rationale
Keeping a walker at the end of the bed can be helpful for some patients, but it’s not the best indication that the patient understands home safety instructions. It’s important that the walker is used correctly and that the patient’s home is arranged to accommodate its use.

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A nurse at an extended-care facility is instructing a class of assistive personnel (AP) about the use of assistive devices during client ambulation. Which of the following instructions should the nurse include about assisting clients who use a cane?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is preparing to administer an intradermal injection for a client who requires a tuberculin skin test. What actions should the nurse plan to take?

Correct Answer is C

Explanation

A nurse is reinforcing home safety instructions for a patient with a history of falls. Which statement should the nurse identify as an indication that the patient understands the instructions?

Correct Answer is A

Explanation

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A nurse at an extended-care facility is instructing a class of assistive personnel (AP) about the use of assistive devices during client ambulation.
Which of the following instructions should the nurse include about assisting clients who use a cane?