A nurse is teaching a client about using a cane for ambulation. Which of the following statements should the nurse make?

"Advance the cane 12 inches forward when walking."

"Keep the cane at the same level as the affected leg when climbing stairs."

"Hold the cane on the side of your affected leg when walking."

"Move your unaffected leg before your affected leg when walking."

Answer and Explanation

The Correct Answer is D

A. "Advance the cane 12 inches forward when walking." Advancing the cane 12 inches forward is not practical; the cane should be moved in a manner that aligns with the client's steps for better balance and support. The movement of the cane should be synchronized with the client's stride rather than a fixed distance.
B. "Keep the cane at the same level as the affected leg when climbing stairs." When climbing stairs, the cane should be held on the side of the unaffected leg to provide optimal support and balance. Keeping the cane level with the affected leg is incorrect and does not provide adequate support.
C. "Hold the cane on the side of your affected leg when walking." The cane should be held on the side opposite the affected leg to provide better stability and support. Holding the cane on the affected side would not offer the necessary support for effective ambulation.
D. "Move your unaffected leg before your affected leg when walking." This is the correct technique as it ensures better balance and stability. Moving the unaffected leg first while using the cane allows for a more secure and coordinated gait, reducing the risk of falls.

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Correct Answer is ["B","C","D"]

Explanation

A. Tell the client there is nobody else in the room: This action is not appropriate as it does not address the immediate clinical needs of the client. Providing comfort and managing symptoms is a priority at the end of life.
B. Turn the client on their side: This action helps in relieving pressure, preventing aspiration, and improving respiratory function, which is particularly beneficial when a client is experiencing irregular and shallow breathing.
C. Place a fan to blow lightly toward the client: A fan can help alleviate discomfort from labored breathing and provide a cooling effect, which can be soothing for the client and improve their comfort.
D. Administer an opioid narcotic to the client: Opioids can help manage pain and dyspnea in end-of-life care, improving the client's comfort and quality of life by relieving symptoms of distress.
E. Provide deep nasotracheal suctioning for the client: This action is typically not recommended at the end of life as it can cause discomfort and distress without significant benefit. Gentle suctioning, if necessary, should be performed cautiously and with attention to the client's comfort.

A. Placing a high risk for falls armband on the patient B. Checking on the patient once a shift C. Keep the bed in the lowest position D. Placing all four side rails in the "up" position E. Maintain call light within reach of the patient

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

Explanation

A. Placing a high risk for falls armband on the patient: An armband alerts all healthcare providers to the patient's fall risk, helping to ensure appropriate precautions are taken.
B. Checking on the patient once a shift: This is not sufficient; patients on fall precautions should be checked more frequently, such as every hour or according to the facility's protocol, to ensure their safety.
C. Keep the bed in the lowest position: Keeping the bed at its lowest position reduces the risk of injury from falls and helps ensure the patient can easily get in and out of bed.
D. Placing all four side rails in the "up" position: Using all four side rails is not recommended as it can increase the risk of entrapment and may not be effective in preventing falls. Side rails should be used appropriately and in accordance with safety protocols.
E. Maintain call light within reach of the patient: Ensuring the call light is within reach helps the patient call for assistance if needed, which can help prevent falls.

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A nurse is teaching a client about using a cane for ambulation. Which of the following statements should the nurse make?

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Naxlex Comprehensive Predictor Exams

Correct Answer is ["B","C","D"]

Explanation

The client has been admitted and placed on fall precautions. The nurse explains to the patient that interventions for the precautions include: (Select All that Apply)

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

Explanation

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