A nurse is teaching a client who has left-sided weakness after a stroke on how to use a cane. What instructions should the nurse include?

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

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

Remove the rubber tip when using the cane.

Place the cane approximately 61 cm (24 inches) in front of her foot before advancing.

Answer and Explanation

The Correct Answer is A

Choice A reason: Holding the cane on the opposite side of the weaker leg is the correct technique. For a client with left-sided weakness, holding the cane on the right side provides better support and balance. This method helps distribute weight away from the weaker side and reduces the risk of falls. The cane should be moved simultaneously with the weaker leg to maintain stability.

Choice B reason: Advancing the right leg and the cane together is incorrect. The correct technique involves moving the cane and the weaker leg (left leg in this case) together. This coordination helps in maintaining balance and provides the necessary support to the weaker side. Moving the stronger leg and the cane together does not offer the same level of support.

Choice C reason: Removing the rubber tip when using the cane is not advisable. The rubber tip provides traction and prevents the cane from slipping on various surfaces. Removing it would increase the risk of falls and injuries. The rubber tip is an essential safety feature of the cane.

Choice D reason: Placing the cane approximately 61 cm (24 inches) in front of the foot is too far. The cane should be placed about 15-20 cm (6-8 inches) in front of the foot to ensure stability and ease of movement. Placing the cane too far ahead can cause instability and make walking more difficult.

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Correct Answer is A

Explanation

Choice A Reason:

Mobilizes secretions is correct. Expectorants work by thinning and loosening the mucus in the airways, making it easier to cough up and expel. This helps clear the respiratory tract of mucus and other secretions, making the cough more productive.

Choice B Reason:

Suppresses the urge to cough is incorrect. This describes the action of antitussives, not expectorants. Antitussives work by suppressing the cough reflex, which is different from the mechanism of expectorants.

Choice C Reason:

Reduces inflammation is incorrect. While reducing inflammation can help with respiratory symptoms, it is not the primary mechanism of action for expectorants. Anti-inflammatory medications are used to reduce inflammation.

Choice D Reason:

Dries mucous membranes is incorrect. Drying mucous membranes is typically the action of antihistamines, not expectorants. Expectorants aim to increase the moisture in mucus to make it less sticky and easier to expel.

A. Providing a bed bath B. Assisting in toileting C. Evaluate effectiveness of a treatment D. Assessment of a stoma E. Discharge teaching

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

Explanation

Choice A Reason:

Providing a bed bath is a task that can be delegated to unlicensed assistive personnel (UAP). This task is routine and does not require clinical judgment or advanced nursing skills. UAPs are trained to perform basic care activities such as bathing, which helps maintain the client’s hygiene and comfort.

Choice B Reason:

Assisting in toileting is another task that can be delegated to UAPs. This task involves helping clients with their toileting needs, which is within the scope of practice for UAPs. It does not require the clinical judgment or assessment skills that are reserved for licensed nurses.

Choice C Reason:

Evaluating the effectiveness of a treatment is a task that cannot be delegated to UAPs. This task requires clinical judgment and the ability to assess the client’s response to treatment, which are responsibilities of licensed nurses. Only licensed nurses have the training and expertise to evaluate treatment outcomes and make necessary adjustments.

Choice D Reason:

Assessment of a stoma is a task that cannot be delegated to UAPs. Assessing a stoma involves evaluating its appearance, function, and any signs of complications, which requires clinical judgment and expertise. This task is within the scope of practice for licensed nurses, who are trained to perform comprehensive assessments.

Choice E Reason:

Discharge teaching is a task that cannot be delegated to UAPs. Discharge teaching involves providing clients with important information about their care after leaving the healthcare facility, including medication instructions, follow-up appointments, and lifestyle modifications. This task requires clinical knowledge and the ability to educate clients effectively, which are responsibilities of licensed nurses.

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A nurse is teaching a client who has left-sided weakness after a stroke on how to use a cane. What instructions should the nurse include?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is teaching a client about taking an expectorant to treat a cough. The nurse should explain this type of medication works by which mechanism?

Correct Answer is A

Explanation

The nurse is providing education to a student nurse regarding delegation. What tasks would be unable to be delegated to unlicensed assistive personnel (UAP)? (Select all that apply)

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

Explanation

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