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 B

Explanation

Choice A rationale
Turning the torso at the waist when reaching for objects can actually increase the risk of back injury. It’s important to keep the back straight and bend at the knees when lifting or reaching for objects.
Choice B rationale

Using ice packs intermittently for 48 hours is a common recommendation for acute lower back pain. Ice can help reduce inflammation and numb the area, providing relief. It’s important to use the ice packs intermittently, not continuously, to avoid frostbite.
Choice C rationale
Using 10 lb arm weights to start strengthening the back muscles is not recommended for someone with acute lower back pain. Heavy lifting can exacerbate the pain and potentially cause further injury. It’s better to start with gentle, low-impact exercises and gradually increase intensity as the back heals.
Choice D rationale
Staying in bed except for toileting during the first 24 hours is not typically recommended for acute lower back pain. While rest is important, prolonged bed rest can actually lead to muscle stiffness and increased pain. It’s generally recommended to stay as active as possible without exacerbating the pain.

A. Place a 1-inch needle on the syringe. B. Hold the syringe at a 20° angle to the client’s skin. C. Draw up 0.5 mL of purified protein derivative (PPD) from the vial. D. Pinch the skin at the chosen site with the non-dominant hand before inserting the needle.

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.

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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 nurse is discussing with a patient who has reported acute lower back pain after lifting heavy boxes. What information should the nurse emphasize?

Correct Answer is B

Explanation

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

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