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 D
Explanation
A. A metallic taste in the mouth is a common side effect of the contrast dye used in IV urography procedures and is not typically a cause for concern.
B. Abdominal fullness may occur due to the administration of fluids during the procedure and is not usually a priority finding unless it persists or is severe.
C. Feeling flushed and warm may be a transient reaction to the contrast dye and does not typically require immediate intervention unless accompanied by other symptoms.
D. Swollen lips could indicate an allergic reaction to the contrast dye, which can progress rapidly and potentially lead to a severe reaction such as anaphylaxis. This is the priority finding requiring immediate attention.
Correct Answer is C
Explanation
A. "Rub your child's gums with an aspirin tablet before bedtime." - Aspirin is not recommended for children due to the risk of Reye's syndrome, a potentially fatal condition.
B. "Place an amber teething necklace on your child before bedtime." - Amber teething necklaces pose a choking hazard and are not recommended for infants.
C. "Administer acetaminophen drops to your child before bedtime." - Acetaminophen is a safe and effective pain reliever for infants and can help alleviate discomfort associated with teething, which may improve sleep.
D. "Apply a teething product containing benzocaine to your child's gums before bedtime." -
Benzocaine-containing products are not recommended for infants due to the risk of methemoglobinemia, a potentially life-threatening condition.
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