A nurse is monitoring a client who ambulates with a cane. Which of the following actions by the client should the nurse expect?

The client holds the cane on the stronger side of their body.

The top of the cane is at the same height as the client's waist.

The client moves their stronger leg forward first.

The client advances the cane forward 12.7 cm (5 in).

Answer and Explanation

The Correct Answer is A

A. The client holds the cane on the stronger side of their body.: Holding the cane on the unaffected (stronger) side provides a wider base of support and shifts weight away from the weaker leg.

B. The top of the cane is at the same height as the client's waist.: The top of the cane should reach the level of the greater trochanter or the wrist crease.

C. The client moves their stronger leg forward first.: The cane and the weaker leg should move forward together first, followed by the stronger leg.

D. The client advances the cane forward 12.7 cm (5 in).: Standard instruction is to advance the cane 15 to 25 cm (6 to 10 inches) to maintain stability.

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Correct Answer is C

Explanation

A. The grounding pad is positioned near the surgical site.: The grounding pad (for electrocautery) should be placed over a large, well-vascularized muscle mass, away from the surgical site and bony prominences.

B. The client's surgical site is shaved with a razor.: Razors create "micro-cuts" that increase the risk of surgical site infections. Clippers are preferred if hair removal is necessary.

C. The client is positioned to minimize pressure on the skin.: During surgery, clients are unable to move or feel pain. Proper padding and positioning are essential to prevent pressure injuries and nerve damage.

D. The client is covered with a cooling blanket.: Maintaining normothermia (normal body temperature) is critical for healing and preventing infection; warming blankets are typically used.

A. Store the oxygen cylinder wrench with the oxygen tank. B. Take steroid medication in the morning. C. Decrease the steroid dose each day. D. Take antibiotic medication with or without food. E. Adjust the oxygen flow rate as needed to ease breathing. F. Ensure the oxygen delivery system G. Take antibiotics for 10 days.

Correct Answer is ["A","B","D","F"]

Explanation

A. Store the oxygen cylinder wrench with the oxygen tank.: The wrench is necessary to open the oxygen tank in an emergency or when changing tanks. Keeping it with the tank ensures it is immediately available for the client or caregiver.

B. Take steroid medication in the morning.: Prednisone (a corticosteroid) can cause insomnia and restlessness. Taking it in the morning aligns with the body's natural circadian rhythm of cortisol production and helps prevent sleep disturbances.

C. Decrease the steroid dose each day.: The prescription states "40 mg PO daily for 5 days." The nurse should instruct the client to take the full dose as prescribed. While steroids are often tapered, the client should not self-taper unless specifically directed by the provider's prescription.

D. Take antibiotic medication with or without food.: Cephalexin can be taken without regard to meals. However, if the medication causes GI upset, taking it with food can help mitigate nausea.

E. Adjust the oxygen flow rate as needed to ease breathing.: Oxygen is considered a medication. The client must maintain the prescribed flow rate (3 L/min) and should never adjust it without a provider's order, as excessive oxygen can be harmful to some patients.

F. Ensure the oxygen delivery system is at least 8 feet from any heat source.: Oxygen supports combustion. To prevent fires, tanks and concentrators must be kept away from open flames, space heaters, candles, or gas stoves. Standard safety guidelines usually recommend 5 to 10 feet (8 feet is a safe middle ground).

G. Take antibiotics for 10 days.: The prescription specifically states "every 6 hr for 5 days." Taking medications for longer than prescribed is incorrect instruction.

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A nurse is monitoring a client who ambulates with a cane. Which of the following actions by the client should the nurse expect?

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