A nurse is providing home safety information for an older adult client who uses a cane. Which of the following statements should the nurse include in the teaching?

You should advance your weak leg forward to the cane, then move your strong leg

You should advance the cane 12 to 14 inches before taking a step.

The cane’s height should be the same as the distance from the floor to the crest of your hip bone?

You should hold the cane in your weak hand when ambulating

Answer and Explanation

The Correct Answer is C

A. You should advance your weak leg forward to the cane, then move your strong leg:
Advancing the weak leg first and then the strong leg is not the proper technique for using a cane. The correct method is to hold the cane on the stronger side and move the cane and the weaker leg forward together, followed by the stronger leg.

B. You should advance the cane 12 to 14 inches before taking a step:
Advancing the cane 12 to 14 inches is too far. The cane should be advanced approximately 6 to 10 inches to maintain balance and support.

C. The cane’s height should be the same as the distance from the floor to the crest of your hip bone:
The correct height for a cane is when the handle is at the level of the wrist when the user is standing with the arm hanging naturally at their side. This typically corresponds to the distance from the floor to the greater trochanter (hip bone). This ensures the cane provides the right amount of support and reduces the risk of strain or imbalance.

D. You should hold the cane in your weak hand when ambulating:
The cane should be held in the stronger hand, not the weak hand. This allows the cane to provide support to the weaker side of the body and helps to balance the weight distribution more effectively.

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Correct Answer is B

Explanation

A) Delayed gastric emptying: This condition refers to a slowdown in the movement of food from the stomach to the small intestine, often leading to symptoms like nausea, vomiting, bloating, and early satiety. It is not related to breath sounds and would not be detected through auscultation of the lungs.

B) Atelectasis: This condition involves the collapse or closure of lung tissue, resulting in reduced or absent gas exchange. It commonly occurs in patients who are immobile or on bedrest for extended periods, such as the client with a lacerated spleen. Decreased breath sounds in the lower lobes of the lungs are a typical finding in atelectasis, as the collapsed or partially collapsed alveoli do not allow air to move through them, leading to diminished or absent breath sounds in the affected areas.

C) An upper respiratory infection: This condition involves infections in the nose, throat, and airways and typically presents with symptoms like cough, nasal congestion, sore throat, and sometimes fever. It can affect breath sounds, but it more commonly causes wheezing, crackles, or rhonchi rather than isolated decreased breath sounds in the lower lobes.

D) Pulmonary edema: This condition is characterized by the accumulation of fluid in the lungs, often due to heart failure or acute lung injury. Auscultation findings typically include crackles or rales, particularly in the lower lung fields, but not necessarily decreased breath sounds unless there is a significant consolidation or fluid volume.

A. Allow the client to rest for 10 to 15 seconds after each suctioning attempt. B. Set the suction pressure to 110 mm Hg C. Apply suction for less than 10 seconds. D. Apply suction when inserting the catheter.

Correct Answer is ["A","C"]

Explanation

A) Allow the client to rest for 10 to 15 seconds after each suctioning attempt: Allowing the client to rest between suctioning attempts helps to minimize hypoxemia and reduces the risk of trauma to the airway mucosa. It also allows the client to recover from the physiological stress of suctioning before initiating another attempt.

C) Apply suction for less than 10 seconds: Prolonged suctioning can lead to hypoxemia and tissue trauma. The nurse should limit suctioning to less than 10 seconds per pass to minimize these risks and prevent complications such as mucosal damage and bleeding.

B) Set the suction pressure to 110 mm Hg: The appropriate suction pressure for endotracheal suctioning depends on various factors, including the client's age, condition, and clinical status. While suction pressures of 80 to 120 mm Hg are commonly used for adults, the specific pressure setting should be individualized based on the client's needs and should not exceed the safe range to prevent mucosal injury or hypoxemia.

D) Apply suction when inserting the catheter: Suction should be applied only during withdrawal of the catheter to minimize the risk of mucosal trauma and hypoxemia. Applying suction during catheter insertion can increase the risk of airway trauma and should be avoided.

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A nurse is providing home safety information for an older adult client who uses a cane. Which of the following statements should the nurse include in the teaching?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who experienced a lacerated spleen and has been on bedrest for several days. The nurse auscultates decreased breath sounds in the lower lobes of both lungs. The nurse should realize that this finding is most likely an indication of which of the following conditions?

Correct Answer is B

Explanation

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Correct Answer is ["A","C"]

Explanation

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