A nurse is teaching a client who requires maximal support about how to use a two-wheeled walker. Which of the following actions by the client indicates an understanding of teaching?

The client stoops slightly forward when moving the walker.

The client moves the walker ahead 25.4 cm (10 in) with each step.

The client stands with her elbows slightly ﬂexed while holding the walker.

The client picks up the walker with each step.

Answer and Explanation

The Correct Answer is C

When using a two-wheeled walker, the client should stand with their elbows slightly ﬂexed while holding the walker. This allows for proper posture and support while using the walker.

Option a is incorrect because stooping forward can cause strain on the back and neck.

Option b is incorrect because moving the walker too far ahead can cause instability and increase the risk of falls.

Option d is incorrect because picking up the walker with each step can cause fatigue and decrease the eﬀectiveness of the walker.

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Correct Answer is ["480"]

Explanation

480 mL.

The client's total oral intake over the 4-hour period is 3 ounces of milk + 2 ounces of orange juice + 3 ounces of tea + 4 ounces of water = 12 ounces. Since there are approximately 30 mL in 1 ounce, the client's oral intake in mL is 12 ounces * 30 mL/ounce = 360 mL.

The client is also receiving dextrose 5% in 0.45% sodium chloride at a rate of 30 mL/hr by continuous IV infusion. Over a 4-hour period, the client will receive a total of 30 mL/hr * 4 hours = 120 mL from the IV infusion.

Therefore, the client's total intake for that 4-hour period is 360 mL (oral intake. + 120 mL (IV infusion) = 480 mL.

A. Use a separate, sterile swab for each stroke when cleaning the wound. B. First clean the drain site and then clean the incision. C. Don clean gloves before cleaning the wound. D. Cut a 4 x 4 piece of gauze to place around the drain site.

Correct Answer is A

Explanation

When completing a dressing change on a client who has a surgical wound drain, the nurse should use a separate, sterile swab for each stroke when cleaning the wound. This helps to prevent the spread of infection and ensures that the wound is properly cleaned.

Option b is incorrect because the nurse should first clean the incision and then clean the drain site.

Option c is incorrect because the nurse should don sterile gloves before cleaning the wound.

Option d is incorrect because the nurse should not cut a 4 x 4 piece of gauze to place around the drain site; instead, the nurse should use a pre-cut drain sponge.

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A nurse is teaching a client who requires maximal support about how to use a two-wheeled walker. Which of the following actions by the client indicates an understanding of teaching?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is ["480"]

Explanation

A nurse is completing a dressing change on a client who has a surgical wound drain. Which of the following actions should the nurse take?

Correct Answer is A

Explanation

A nurse is assessing a client who is receiving a blood transfusion. The nurse notes lung crackles, hypoxia, and distended neck veins. Which of the following actions should the nurse take? (Select all that apply.)

A nurse is reviewing client confidentiality with a newly licensed nurse. The nurse should identify which of the following examples as a violation of HIPAA?

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