A nurse is planning care for a client who is prescribed a cane for ambulation. Which of the following nursing actions should the nurse include in the plan of care?
Remind the client to place the cane on the unaffected side.
Adjust the length of the cane to equal the distance from the client's iliac crest to the floor.
Remove the rubber tip from the cane to enhance ambulation.
Place the cane safely in the closet during naps and at bedtime.
The Correct Answer is A
A. Placing the cane on the unaffected side helps to provide better support and balance for the client. It allows the client to shift weight away from the affected side, reducing strain and risk of falls.
B. The cane should be adjusted to the height of the wrist crease when the client stands with arms relaxed at their sides, not the iliac crest. This ensures proper posture and effective use of the cane.
C. Removing the rubber tip from the cane is unsafe as the rubber tip provides traction and prevents slipping. Without it, the cane could easily slide on smooth surfaces, increasing the risk of falls.
D. Placing the cane in the closet during naps and bedtime is not practical. The client may need to use the cane immediately upon waking, and it should be easily accessible to prevent accidents.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. The child develops a dry, hacking cough: This suggests ineffective clearance of secretions and may indicate a need for further intervention.
B. The child has increased nasal secretions: Nasal secretions are not directly related to the effectiveness of high-frequency chest compressions in clearing pulmonary secretions.
C. The child has increased sputum production: Increased sputum production indicates that the
treatment is effectively mobilizing and clearing mucus from the airways, which is beneficial for a child with cystic fibrosis.
D. The child develops diminished breath sounds: Diminished breath sounds could indicate a complication such as atelectasis or pneumothorax and would not be an expected finding with effective high-frequency chest compressions.
Correct Answer is A
Explanation
A.
A. A BMI of 20 falls within the healthy weight range for adults.
B. Malnutrition is characterized by a BMI below the healthy weight range and is typically associated with BMI values less than 18.5.
C. Overweight is characterized by a BMI between 25 and 29.9.
D. Obesity is characterized by a BMI of 30 or higher.
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