A nurse is helping an older adult client ambulate in the hallway for the first time since admission. The client has brought a standard walker from home. To ensure proper use of the walker and the safety of the client, 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

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

To ensure proper use of a standard walker and the safety of the client, the nurse should check that the client lifts the walker and then places it down in front of her. This sequence of lifting and moving the walker forward provides stability and support during ambulation.

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

The nurse should walk beside or slightly behind the client to provide support and supervision. Walking in front may hinder the client's ability to maneuver the walker.

C. Have the client move one leg forward with the walker.

The proper technique is for the client to move the walker forward and then step into it with the affected leg. Moving one leg forward with the walker may compromise stability.

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

The correct height of the walker is essential for proper use. The walker should be adjusted to the client's height, with the top bar at the level of the client's wrists when their arms are at their sides, not at the waist.

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Correct Answer is B

Explanation

A. Electrolyte imbalances

Administering diluted enteral feedings is not typically done to address electrolyte imbalances. Instead, monitoring the electrolyte levels in the patient's blood and adjusting the content of the enteral formula (such as adjusting the concentration of electrolytes) would be more appropriate.

B. Diarrhea

Administering diluted enteral feedings is a strategy that may be employed to prevent or manage diarrhea. High concentrations of nutrients can overwhelm the gastrointestinal tract, leading to diarrhea. Diluting the formula helps reduce the risk of this complication.

C. Constipation

Administering diluted enteral feedings is not typically done to address constipation. Management of constipation is more commonly achieved through adjustments in fiber intake, fluid intake, and medications as needed.

D. Delayed gastric emptying

Administering diluted enteral feedings is not a standard approach for addressing delayed gastric emptying. Instead, adjustments in the rate of enteral feedings or specific interventions for delayed gastric emptying, such as medication or changes in positioning, would be considered.

A. “Skeletal traction has less risk for infection than skin traction.” B. “Clients in skin traction have more mobility than those in skeletal traction.” C. “Skeletal traction is better than skin traction for reducing a fracture.” D. “Clients in skin traction have more discomfort than those in skeletal traction.”

Correct Answer is C

Explanation

A. "Skeletal traction has less risk for infection than skin traction."

This statement is not accurate. Both skeletal and skin traction carry some risk of infection, but the risk factors and considerations are different for each. Skeletal traction involves pins or wires directly inserted into the bone, and while the risk of infection is present, it is not necessarily lower than that of skin traction.

B. "Clients in skin traction have more mobility than those in skeletal traction."

This statement is not accurate. Skeletal traction, involving the use of weights and pins or wires inserted into the bone, tends to provide more stable immobilization. Skin traction, which relies on external devices applied to the skin's surface, may allow for some limited mobility but is generally not as effective as skeletal traction.

C. "Skeletal traction is better than skin traction for reducing a fracture."

This is the correct statement. Skeletal traction is often more effective in providing a stable and controlled environment for reducing and immobilizing fractures.

D. "Clients in skin traction have more discomfort than those in skeletal traction."

This statement is not necessarily accurate. Discomfort can vary depending on the individual, the type of fracture, and other factors. Both skeletal and skin traction may cause some discomfort, and it's important to assess and manage the client's pain appropriately in either case.

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

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who is receiving enteral tube feedings of a diluted formula. Which of the following complications of enteral tube feeding should the nurse identify as a reason to administer diluted feedings to clients?

Correct Answer is B

Explanation

A nurse is discussing skeletal and skin traction with a newly licensed nurse. Which of the following statements should the nurse identify as an indication that the newly licensed nurse understands these therapies?

Correct Answer is C

Explanation

A nurse is planning a diet for a client who has an iron deficiency. To increase the client’s iron intake, which of the following foods should the nurse provide in the client’s diet?

A nurse caring for a client who has a chest tube to water-seal drainage plans to straighten the client’s bed linens, rub her back, and assist her to reposition in bed. For which of the following purposes should the nurse perform these actions for this client?

A nurse is caring for a client who has a history of pancreatitis. Which of the following food choices should the client avoid?

A nurse is reinforcing teaching about management of constipation during pregnancy with a group of pregnant clients who are pregnant. Which of the following statements should the nurse include in the teaching?

A nurse is caring for a client who has a fracture of the right hip. Which of the following types of traction should the nurse expect the client to have prior to hip surgery?

A client returns to the surgical unit from the PACU in skeletal traction. The nurse should take action to correct which of the following problems with the traction setup?

A client tells the nurse that he suspects that he grinds his teeth at night. Along with giving the client a dental referral, the nurse should explain that the client should see a dentist for this problem, which she should document as which of the following disorders?

A nurse is assisting with the food tray for a client who is partially blind following a left-sided stroke. Which of the following nursing interventions promotes client independence?