A nurse is teaching a client about the correct use of a cane. Which of the following instructions should the nurse include in the teaching? (Select all that apply.)

Ensure the cane has a rubber cap.

Hold the cane on the weaker side.

Flex the elbow slightly when using the cane.

Move the cane and stronger leg forward simultaneously.

Use a quad cane for increased support.

Answer and Explanation

Correct Answer : A,C,E

A. Ensure the cane has a rubber cap. A rubber cap provides stability and prevents slipping, reducing fall risk.

B. Hold the cane on the weaker side. The cane should be held on the stronger side to provide support while stepping forward with the weaker leg.

C. Flex the elbow slightly when using the cane. The elbow should be slightly flexed (15-30 degrees) when holding the cane for optimal support and comfort.

D. Move the cane and stronger leg forward simultaneously. The cane and weaker leg should move forward together to maintain balance, followed by the stronger leg stepping forward.

E. Use a quad cane for increased support. A quad cane provides a broader base of support and is recommended for clients who need extra stability.

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Correct Answer is A

Explanation

A. Nausea: Nausea is a sign of intolerance to enteral feedings and may indicate delayed gastric emptying or feeding that is too rapid. The nurse should slow the rate of feeding, assess for abdominal distention, and check for residual volume.

B. Urine output 40 mL/hr: Urine output of 40 mL/hr is within the normal range (≥30 mL/hr) and does not indicate intolerance to enteral feedings. However, a significant decrease in urine output (oliguria) could indicate dehydration or kidney issues.

C. Soft stools: Soft stools can be a normal response to enteral feedings unless the client develops diarrhea. Watery, frequent stools may indicate malabsorption, but soft stools alone are not a sign of feeding intolerance.

D. Headache: Headaches are not a common symptom of enteral feeding intolerance. They may be related to other issues such as dehydration, hypertension, or medication side effects.

A. Presence of WBCs in urine B. Cloudy urine C. Urinary urgency D. Bladder distention

Correct Answer is D

Explanation

A. Presence of WBCs in urine : This suggests a possible infection, not necessarily a blockage.

B. Cloudy urine : This may indicate an infection but is not specific for occlusion.

C. Urinary urgency: A client with a catheter should not experience urgency since urine continuously drains.

D. Bladder distention: If the catheter is occluded, urine will accumulate in the bladder, leading to distention.

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A nurse is teaching a client about the correct use of a cane. Which of the following instructions should the nurse include in the teaching? (Select all that apply.)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is monitoring a client who has been receiving intermittent enteral feedings which of the following findings should the nurse identify as an indication of intolerance to the feeding?

Correct Answer is A

Explanation

A nurse is caring for a client who has an Indwelling urinary catheter. Which of the following findings should the nurse Identify as an indication of a possible catheter occlusion?

Correct Answer is D

Explanation

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