A nurse is assisting an older adult client in the hallway for the first time since admission. The client has brought a standard walker from home.To ensure the client’s safety and proper use of the walker, which of the following actions should the nurse take?

Check that the client lifts the walker and then places it down in front of her.

Walk in front of the client to guide her in moving the walker.

Have the client move one leg forward with the walker.

Make sure that the upper bar of the walker is level with the client’s waist.

Answer and Explanation

The Correct Answer is A

Choice A rationale

The client should lift the walker and place it down in front of her. This is because lifting the walker provides stability and support as the client moves. It’s important for the client to move the walker first, then step forward to ensure balance and prevent falls.
Choice B rationale
Walking in front of the client to guide her in moving the walker is not the best practice. The client should be allowed to set the pace and the nurse should be beside or slightly behind the client to provide assistance if needed.
Choice C rationale
Having the client move one leg forward with the walker is not the most effective way to use a walker. Both legs should move forward after the walker has been placed down in front of the client.
Choice D rationale
Making sure that the upper bar of the walker is level with the client’s waist is a good practice, but it’s not the best answer for this question. The height of the walker should be adjusted so that the handles are at the level of the client’s wrists when the client’s arms are hanging down. This allows the client to maintain a slight bend in their elbows when holding the handles.

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Correct Answer is D

Explanation

Choice A rationale
Pursed-lip breathing can help improve oxygenation and reduce shortness of breath in clients with COPD. However, it is not the priority action when a client reports difficulty breathing.
Choice B rationale
Increasing the oxygen flow rate without a physician’s order can lead to oxygen toxicity or suppress the respiratory drive in clients with COPD. Therefore, this is not the priority action.
Choice C rationale
Coughing and expectorating secretions can help clear the airways, but it is not the priority action when a client reports difficulty breathing.

Choice D rationale
Evaluating the client’s respiratory status is the priority action. The nurse should assess the client’s breath sounds, respiratory rate, use of accessory muscles, and oxygen saturation to determine the severity of the client’s difficulty breathing and guide further interventions.

A. “I’ll use a humidifier beside my bed at night.”. B. “I am going to try to lose about 50 pounds.”. C. “I’ll sleep better if I take a sleeping pill at night.”. D. “I am going to have a glass of red wine before bedtime.”.

Correct Answer is B

Explanation

Choice A rationale
Using a humidifier beside the bed at night may not necessarily decrease the number of apneic episodes in a client with obstructive sleep apnea. While a humidifier can help moisten the airways and may provide some relief from symptoms such as dry mouth or throat, it does not address the underlying issue of airway obstruction.
Choice B rationale
Losing weight can indeed help decrease the number of apneic episodes in a client with obstructive sleep apnea. Obesity is a major risk factor for sleep apnea, as excess fat tissue can thicken the wall of the windpipe, making it narrower and making it harder to keep open.
Therefore, losing weight can help reduce this fat and widen the airway, leading to fewer apneic episodes.
Choice C rationale
Taking a sleeping pill at night may actually worsen obstructive sleep apnea. While it might help the client fall asleep, it can also relax the muscles of the throat, which can make the airway more likely to collapse during sleep, leading to more apneic episodes.

Choice D rationale
Drinking a glass of red wine before bedtime is not recommended for a client with obstructive sleep apnea. Alcohol can relax the muscles in the throat and can disrupt the normal sleep cycle, both of which can lead to more apneic episodes.

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A nurse is assisting an older adult client in the hallway for the first time since admission. The client has brought a standard walker from home.To ensure the client’s safety and proper use of the walker, which of the following actions should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A home health nurse is visiting a client who has COPD and is receiving oxygen at 2 L/min via nasal cannula. The client reports difficulty breathing.What is the nurse’s priority action?

Correct Answer is D

Explanation

A nurse is reinforcing teaching with a client who is obese and has obstructive sleep apnea about how to decrease the number of apneic episodes he has each night.Which statement indicates that the client understands the instructions?

Correct Answer is B

Explanation

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