A nurse is creating home instructions for a client who has immunodeficiency. Which of the following statements by the client indicates an understanding of the teaching?

Choice A reason:

Walking in front of the client to guide her in moving the walker is not recommended. The nurse should walk beside or slightly behind the client to provide support and ensure safety. Walking in front can obstruct the nurse’s view of the client’s movements and make it difficult to assist if the client loses balance.

Choice B reason:

Ensuring that the upper bar of the walker is level with the client’s waist is incorrect. The correct height for the walker is when the client’s elbows are slightly bent (about 15-30 degrees) when holding the handgrips. This allows for better control and reduces the risk of falls.

Choice C reason:

Having the client move one leg forward with the walker is not the correct technique. The client should first lift the walker and place it a short distance ahead, then step forward with the weaker leg first, followed by the stronger leg. This method provides better stability and support.

Choice D reason:

Checking that the client lifts the walker and then places it down in front of her is the correct action. This ensures that the walker is used properly, providing maximum support and reducing the risk of tripping or falling. The client should lift the walker, move it forward, and then step into the walker area.

Choice A reason:

The statement “Reposition the client a second time before assessing his respirations” is not appropriate in this scenario. If the client remains apneic after the initial airway repositioning, further repositioning is unlikely to be effective. Immediate action is required to determine the next steps in care.

Choice B reason:

The statement “Place a red tag on the client’s upper body and obtain immediate help from other personnel” is incorrect. A red tag is used for patients who require immediate medical attention and have a chance of survival with timely intervention. Since the client remains apneic despite airway repositioning, they are unlikely to survive without immediate advanced medical intervention, which may not be feasible in a mass casualty situation.

Choice C reason:

The statement “Place a black tag on the client’s upper body and attempt to help the next client in need” is correct. In a mass casualty incident, a black tag is used to indicate that a patient is deceased or expected to die due to the severity of their injuries and the lack of available resources to provide the necessary care. Since the client remains apneic with a weak pulse, they are unlikely to survive, and resources should be directed to those with a higher chance of survival.

Choice D reason:

The statement “Start CPR” is not the most appropriate action in this scenario. In a mass casualty situation, resources must be allocated to those who have the best chance of survival. Starting CPR on a client who remains apneic despite airway repositioning may not be the best use of limited resources, especially when other clients may need immediate attention and have a higher chance of survival.