A nurse is assisting an older adult client who sometimes loses her balance while walking. Which of the following devices should the nurse use when helping the client ambulate?
Jacket harness
Four-wheel walker
Cane
Galt belt
The Correct Answer is D
A. A jacket harness is typically used for clients who need more significant support, such as those who are unable to bear weight on their legs. It's not the most appropriate choice for a client who occasionally loses their balance.
B. A four-wheel walker provides more stability than a cane, but it can be difficult for some clients to use, especially those with limited upper body strength.
C. A cane can be helpful for clients who need some support while walking, but it may not provide enough stability for a client who frequently loses their balance.
D. A Galt belt is a wide, padded belt that can be used to assist clients with ambulation. It provides a secure grip without restricting the client's movement and is ideal for clients who occasionally lose their balance.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Before administering an enteral feeding, it's important to discard any residual gastric contents to prevent aspiration. Aspirating and discarding the residual helps to assess gastric emptying and ensure that the stomach is able to tolerate the feeding.
B. While placing the client in a semi-Fowler's position is generally recommended during and after enteral feedings to help prevent aspiration, it's not necessary prior to administering the feeding.
C. Warming the feeding solution to body temperature can help to improve the client's comfort and may reduce nausea. However, it's not a critical step before administering the feeding.
D. Testing the pH of gastric aspirate is important to assess for gastric placement and to ensure that the tube is not in the lungs. However, it's typically done prior to the initial placement of the NG tube and is not routinely repeated before each feeding.
Correct Answer is A
Explanation
A. Checking the stockings for wrinkles is an important action. Wrinkles or folds in the stockings can create areas of increased pressure, which might lead to discomfort or skin breakdown and reduce the effectiveness of the stockings in preventing DVT. Ensuring that the stockings are smooth and free from wrinkles helps maintain proper compression and comfort.
B. Measuring the size of the client's foot is not typically required for properly fitting antiembolic stockings. The key measurements for antiembolic stockings are usually related to the calf, thigh, and sometimes the knee, not the foot.
C. Removing the stockings once each day is not usually recommended unless specifically instructed by a healthcare provider. Antiembolic stockings are generally worn continuously throughout the day and removed only for specific reasons, such as skin assessment or hygiene.
D. Applying the stockings while the client is sitting in a chair is not the preferred method. Antiembolic stockings should be applied while the client is lying down or in a supine position. This helps ensure that the stockings are applied evenly and that they provide consistent compression without causing undue pressure or discomfort.
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