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 B

Explanation

An alternating pressure mattress can help prevent skin breakdown in a client who is immobile by redistributing pressure and reducing the risk of pressure ulcers. This is an appropriate action for the nurse to include in the plan of care for a client who is immobile and has urinary incontinence.

a. An indwelling urinary catheter can increase the risk of infection and should only be used when other methods of managing urinary incontinence are not eﬀective.

c. Cornstarch can absorb moisture and help keep the skin dry, but it is not recommended for use on broken skin or in areas where there is a risk of fungal infection.

d. Repositioning the client every 4 hours may not be frequent enough to prevent skin breakdown. The client should be repositioned at least every 2 hours to reduce the risk of pressure ulcers.

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

A nurse is planning care to prevent skin breakdown for a client who is immobile and has urinary incontinence. Which of the following actions should the nurse include in the plan of care?

Correct Answer is B

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 providing teaching about preventing back strain to the caregiver of a client who is immobile and requires assistance to reposition in bed. Which of the following statements by the caregiver indicates an understanding of the teaching?

A nurse is providing instruction to a client who has diabetes mellitus about foot care. Which of the following statements by the client indicates an understanding of the teaching?

A nurse is planning care for a client who is scheduled for an intravenous pyelogram. Which of the following actions is appropriate for the nurse to include?

A nurse is preparing to palpate a client's systolic blood pressure using the brachial artery. After applying the blood pressure cuﬀ to the client's arm, identify the sequence of steps the nurse should follow. (Arrange the steps, placing them in the order of performance. Use all the steps.)

A nurse is planning care for a client who has a new prescription for parenteral nutrition (PN) in 20% dextrose and fat emulsions. Which of the following is an appropriate action to include in the plan of care?

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?

A nurse is speaking with the partner of a client who is unconscious and has a do-not-resuscitate (DNR) order in place. The partner requests that CPR be performed if necessary. Which of the following responses should the nurse make?

A nurse hangs a bag of dextrose 5% in water, 1,000 mL at 0800 to run at 125 mL/hr. At 1200, the nurse notices that the client's IV bag is empty. Which of the following interventions should the nurse take first?