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 A,C,B,D

Explanation

A. Verify the tube placement.: The nurse must always ensure the tube is in the stomach (via pH testing or X-ray) before putting anything down it to prevent aspiration.

C. Check the client's gastric residual.: This determines if the client is tolerating current feedings and ensures the stomach isn't too full to receive medication.

B. Pour the medication into the syringe and allow it to flow by gravity.: This is the actual administration step.

D. Clamp the NG tube for 20 to 30 min.: Since the tube was on suction, it must remain clamped after administration to allow the medication to be absorbed rather than sucked back out.

A. Put on goggles. B. Put on a gown. C. Don a mask. D. Don gloves.

Correct Answer is B,C,A,D

Explanation

Put on a gown: This protects the nurse's clothing and skin from contamination.
Don a mask: This protects the respiratory tract; it should be fitted before adding eye protection.
Put on goggles: Eye protection is added after the mask to ensure it fits properly over the mask's bridge.
Don gloves: Gloves are put on last and should be pulled up to cover the cuffs of the gown to ensure no skin is exposed.

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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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Naxlex Comprehensive Predictor Exams

A nurse is administering a liquid medication to a client who has an NG tube set to intermittent suction. Identify the sequence of steps the nurse should take when administering the medication. (Move the steps, placing them in the order of performance. Use all the steps.)

Correct Answer is A,C,B,D

Explanation

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Correct Answer is B,C,A,D

Explanation

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