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.
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Naxlex Comprehensive Predictor Exams
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Correct Answer is B
Explanation
A. Diabetes mellitus is not a contraindication for methylergonovine, although blood glucose should be monitored in all postpartum clients.
B. Hypertension is a contraindication because methylergonovine causes vasoconstriction, which can dangerously elevate blood pressure and increase the risk of stroke or other cardiovascular complications.
C. Migraine headaches are not an absolute contraindication, although ergot derivatives can potentially exacerbate migraines in some clients.
D. Hepatitis B is not a contraindication, though liver function should be monitored when using medications metabolized by the liver.
Correct Answer is D
Explanation
A. Detaching the needle from the syringe before discarding it increases the risk of needle-stick injuries. Needles should be disposed of as one unit to minimize the risk of injury.
B. Broken glass should be disposed of in a puncture-proof container to prevent injuries. Placing it directly in a wastebasket increases the risk of puncture injuries to individuals handling the waste.
C. Recapping needles increases the risk of needle-stick injuries. Needles should not be recapped after use unless there is no safer alternative. Instead, they should be disposed of as one unit.
D. Lancets, needles, and other sharp objects should be placed in puncture-proof containers immediately after use to prevent injuries. This practice helps ensure the safety of healthcare workers and others who handle waste.
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