A nurse is instructing a client who has left-sided hemiparesis about the use of a quad cane. Which of the following actions by the client indicates an understanding of the teaching?

The client advances their right foot to meet their left foot.

The client maintains two points of support on the floor.

The client holds the cane in their left hand.

The client moves the cane forward 50.8 cm (20 in) when ambulating.

Answer and Explanation

The Correct Answer is B

B. When using a quad cane, the client should always maintain two points of support on the floor: the cane and either the affected (left) or unaffected (right) leg. This ensures stability and support while walking.

A When using a quad cane, the client should advance their weaker (left) foot and then the stronger (right) foot. This allows the cane to provide support on the weaker side.

C. This action is correct for a client with left-sided hemiparesis. The quad cane should be held on the stronger side (right hand) to provide support for the weaker side (left leg).

D. This statement is unclear in terms of the context provided. However, typically when using a quad cane, the cane is moved forward a comfortable distance with each step to provide continuous support and balance. The exact distance may vary depending on the client's stride length and comfort.

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Correct Answer is D

Explanation

D. Morphine is effective in reducing anxiety due to its sedative and anxiolytic properties. Decreased anxiety can be an indication that morphine is effective in managing symptoms associated with acute heart failure, such as dyspnea and anxiety related to difficulty breathing.

A Morphine is a potent opioid analgesic that can depress the respiratory center, leading to decreased respiratory rate or even respiratory depression in some cases.

B. Vomiting after morphine administration does not indicate effectiveness of the medication in managing acute heart failure symptoms. It is rather a side effect that needs to be managed.

C. Decreased urinary output is not a sign of effectiveness in managing acute heart failure symptoms. It is an adverse effect that needs to be monitored and managed separately.

A. Administer opioids PO. B. Monitor for hypokalemia as a manifestation of acute rejection. C. Assess urine output hourly. D. Check the client's blood pressure every 8 hr.

Correct Answer is C

Explanation

C. Monitoring urine output is crucial in the early postoperative period after a kidney transplant to assess kidney function and ensure adequate perfusion.

A Managing pain is important, but the administration of opioids should be carefully considered due to their potential to mask symptoms and side effects that could be critical in the postoperative period.

B. While electrolyte imbalances are important to monitor, hypokalemia specifically is not typically associated with acute rejection in the early postoperative period.

D. Blood pressure monitoring every 8 hours may not be sufficient in the immediate postoperative period, especially given the potential for fluid shifts and changes in hemodynamic status.

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A nurse is instructing a client who has left-sided hemiparesis about the use of a quad cane. Which of the following actions by the client indicates an understanding of the teaching?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has acute heart failure and received morphine IV 30 min ago. Which of the following findings should the nurse identify as an indication that the medication was effective?

Correct Answer is D

Explanation

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Correct Answer is C

Explanation

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