A nurse is providing discharge teaching to a client who will be using a cane to maintain mobility at home following a left knee arthroplasty. Which of the following statements by the client indicates an understanding of the safe use of a cane?

"I'll use the cane to support my body weight.".

"I will put the cane next to my right leg when I walk.".

"My partner is bringing in a wooden cane we have at home.".

"I will move my right leg forward first.".

Answer and Explanation

The Correct Answer is B

Choice A rationale:

Using the cane to support body weight is not the correct technique. The purpose of a cane is to provide balance and support, not to bear the entire body weight. Placing the entire body weight on the cane can lead to instability and falls.

Choice B rationale:

Placing the cane next to the unaffected leg (right leg in this case) is the correct technique. This positioning provides additional support and stability on the side opposite to the affected leg. This helps in maintaining balance and reducing the risk of falling.

Choice C rationale:

The type of cane is not as relevant as using it correctly. The material of the cane doesn't impact the client's understanding of how to use it safely. While using a wooden cane might be acceptable, the material itself is not an indication of the client's understanding of safe cane use.

Choice D rationale:

Moving the right leg forward first is not the correct technique for using a cane. The correct foot to move forward first is the affected leg, in this case, the left leg. This allows the client to maintain a stable base of support while moving.

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Correct Answer is B

Explanation

Choice A rationale:

Selecting an injection site on the abdomen 5 cm (2 in) from the umbilicus might be an appropriate instruction for some subcutaneous injections, but the specific injection site can vary based on the medication and client's needs. This choice is not a universal instruction for all subcutaneous injections.

Choice B rationale:

Expelling the air bubble from a prefilled syringe before injecting the medication is essential to ensure accurate dosing. Air bubbles can displace medication and lead to underdosing. This step is crucial for safe and effective administration.

Choice C rationale:

Aspirating prior to injecting medication is a technique used for intramuscular injections to ensure the needle is not in a blood vessel. However, for subcutaneous injections, aspirating is not necessary or recommended, as it can cause tissue damage and discomfort.

Choice D rationale:

Inserting the needle at a 15° angle is not a standard practice for subcutaneous injections. Subcutaneous injections are typically administered at a 45° or 90° angle, depending on the needle length and client's body composition. A 15° angle would not ensure proper medication delivery.

A. Verifying placement of a nasogastric tube. B. Evaluating a client's understanding of how to use crutches. C. Replacing the gauze on a skin abrasion. D. Monitoring bowel sounds.

Correct Answer is C

Explanation

Choice A rationale:

Verifying placement of a nasogastric tube requires specialized training and knowledge to ensure correct placement and prevent complications. The nurse should retain this task to ensure patient safety.

Choice B rationale:

Evaluating a client's understanding of how to use crutches involves assessing the client's comprehension and ability to use crutches safely and effectively. This task requires nursing judgment and should not be delegated to an assistive personnel.

Choice C rationale:

Replacing the gauze on a skin abrasion is a task that can be safely assigned to an assistive personnel. It involves basic wound care, which typically falls within the scope of practice for assistive personnel. The AP can be trained to follow established protocols for wound cleaning and dressing changes.

Choice D rationale:

Monitoring bowel sounds requires clinical judgment and the ability to recognize variations from the normal range. The nurse should perform this task, as it involves assessing the client's condition and making appropriate decisions based on the findings.

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A nurse is providing discharge teaching to a client who will be using a cane to maintain mobility at home following a left knee arthroplasty. Which of the following statements by the client indicates an understanding of the safe use of a cane?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is teaching a client about self-administering a subcutaneous injection to the abdomen. Which of the following instructions should the nurse include?

Correct Answer is B

Explanation

A nurse is preparing to assign tasks to an assistive personnel (AP). Which of the following tasks should the nurse assign to the AP?

Correct Answer is C

Explanation

A nurse is assessing a client's coping skills. Which of the following should the nurse identify as an internal stressor?

A nurse is caring for a client who reports using alcohol and controlled substances to cope with the death of their partner. The nurse should identify that maladaptive coping is an indication of which of the following types of complicated grief?

A nurse is reviewing transmission precautions with an assistive personnel (AP) who is providing care for a client who has a Clostridium difficile infection. Which of the following statements by the AP indicates an understanding of the teaching?

A nurse is teaching pursed-lip breathing to a client who has COPD. Which of the following instructions should the nurse include in the teaching?

A nurse receives a telephone call from a client's family member, who asks the nurse for an update on the client's condition. Which of the following actions should the nurse take to maintain the client's confidentiality?

A nurse is teaching the family of a client who has a terminal illness about end-of-life care. Which of the following statements by a family member indicates an understanding of the teaching?

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