A nurse is teaching a client who has left hemiparesis how to use a cane. Which of the following instructions should the nurse include?

Hold the cane on the right side to provide support for the weaker leg

Remove the rubber tip when using the cane.

Advance the right leg and the cane together to support the weaker leg

Place the cane approximately 61 cm (24 in) in front of her feet before advancing

Answer and Explanation

The Correct Answer is A

A: The correct instruction is to hold the cane on the right side, which is the side opposite the weaker leg. This provides better support and balance for the weaker side.

B: Removing the rubber tip from the cane is not recommended. The rubber tip provides traction and stability, reducing the risk of slipping.

C: Advancing the right leg and the cane together is incorrect. The cane should move with the weaker leg (left leg in this case) to provide support during ambulation.

D: Placing the cane 61 cm (24 in) in front of the feet is too far. The cane should be placed about 15-25 cm (6-10 in) in front of the feet to provide optimal support and balance.

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Correct Answer is B

Explanation

A: Obtaining a chest x-ray is important for diagnosing potential complications but is not the immediate first action to improve oxygen saturation.

B: Raising the head of the bed helps improve lung expansion and oxygenation. It is a quick and effective first step to increase oxygen saturation.

C: Administering a prescribed analgesic can help with pain management but does not directly address the low oxygen saturation.

D: Administering oxygen at 2 L/min is important but should follow the initial step of raising the head of the bed to optimize breathing.

A. Blood pressure sitting 140/60; blood pressure 130/60 standing B. Blood pressure sitting 130/60; blood pressure 110/60 standing C. Blood pressure sitting 126/64; blood pressure 120/58 standing D. Blood pressure sitting 130/64; blood pressure 140/70 standing

Correct Answer is B

Explanation

A: A drop in systolic blood pressure of 10 mm Hg (from 140 to 130) does not meet the criteria for orthostatic hypotension, which requires a drop of at least 20 mm Hg in systolic pressure or 10 mm Hg in diastolic pressure within three minutes of standing.

B: This finding shows a drop in systolic blood pressure from 130 to 110 mm Hg, which is a 20 mm Hg decrease. This meets the criteria for orthostatic hypotension, indicating that the patient may have this condition.

C: A drop in systolic blood pressure of 6 mm Hg (from 126 to 120) does not meet the criteria for orthostatic hypotension. The decrease is not significant enough to confirm the condition.

D: An increase in blood pressure (from 130/64 to 140/70) does not indicate orthostatic hypotension. This finding suggests that the patient’s blood pressure increases upon standing, which is not consistent with orthostatic hypotension.

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A nurse is teaching a client who has left hemiparesis how to use a cane. Which of the following instructions should the nurse include?

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