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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["0.4"]
Explanation
Step-by-Step Calculation
Step 1: Identify the desired dose and the concentration of the medication.
Desired dose = 4 mg
Concentration = 10 mg/mL
Step 2: Set up the calculation to find the volume to administer.
Volume to administer (mL) = Desired dose (mg) ÷ Concentration (mg/mL)
Step 3: Perform the division.
4 mg ÷ 10 mg/mL = 0.4 mL
Step 4: Round the answer to the nearest whole number.
0.4 mL rounded to the nearest whole number is 0 mL
Step 5: Apply the instruction to use a leading zero if it applies and do not use a trailing zero.
The final volume to administer is 0.4 mL.
Therefore, the nurse should administer 0.4 mL of furosemide via IV bolus to the client.
Correct Answer is A
Explanation
Choice A reason: Starting chest compressions is the priority intervention for a client who is unresponsive, not breathing, and without a pulse. This situation indicates cardiac arrest, and immediate chest compressions are crucial to maintain circulation and oxygen delivery to vital organs. Early initiation of chest compressions improves the chances of survival and neurological outcomes.
Choice B reason: Obtaining a central line is not an immediate priority in the context of cardiac arrest. While central lines are important for administering medications and fluids, the first step in resuscitation is to establish effective chest compressions. Central line placement can be considered after initial resuscitation efforts are underway.
Choice C reason: Completing a comprehensive assessment is important, but it is not the immediate priority in a cardiac arrest situation. The primary focus should be on initiating chest compressions and basic life support measures. A detailed assessment can be performed once the client is stabilized.
Choice D reason: Providing rescue breathing is part of cardiopulmonary resuscitation (CPR), but it should follow the initiation of chest compressions. Current guidelines emphasize the importance of starting chest compressions immediately and then integrating rescue breaths. Effective chest compressions are the foundation of CPR.
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