The nurse is educating a patient about the use of a cane due to weakness of the left leg.
Which statement by the patient would indicate teaching has been effective?
"I know the cane helps narrow my base of support and improve my balance.”.
"I will assure the tip of the cane is at least 12 inches to the side of the foot.”.
"I am going to adjust the cane so my wrist is lower than the top of the cane.”.
"I will ambulate by advancing first my cane then my weak leg and lastly my strong leg.”.
The Correct Answer is A
Choice A rationale:
This statement indicates effective teaching. Narrowing the base of support and improving balance are key aspects of using a cane properly. A patient who understands this concept demonstrates comprehension of the teaching.
Choice B rationale:
Placing the tip of the cane at least 12 inches to the side of the foot is incorrect. The cane should be placed about 6 inches to the side of the foot for proper support and balance.
Choice C rationale:
Adjusting the cane so the wrist is lower than the top of the cane is incorrect. The top of the cane should be at the level of the wrist for optimal use.
Choice D rationale:
Advancing the cane first, followed by the weak leg and then the strong leg, is incorrect. The correct sequence is advancing the cane and the weak leg simultaneously and then followed by the strong leg to maintain balance and support.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","B","D","E"]
Explanation
Choice A rationale:
Encourage the patient to use an incentive spirometer. Rationale: Encouraging the use of an incentive spirometer helps improve lung function and prevent respiratory complications. It promotes deep breathing and prevents atelectasis, especially in patients experiencing dyspnea.
Choice B rationale:
Auscultate lung sounds bilaterally. Rationale: Auscultating lung sounds helps the nurse assess for abnormal breath sounds, such as wheezing or crackles, which can indicate respiratory distress. This assessment is crucial in managing a patient with dyspnea.
Choice C rationale:
Ambulate the patient in the hall. Rationale: Ambulating the patient can worsen dyspnea in some cases, especially if the patient is experiencing severe respiratory distress. Therefore, this intervention may not be appropriate for a patient with dyspnea.
Choice D rationale:
Position the bed in high fowlers. Rationale: Positioning the patient in high fowlers (sitting upright with the head of the bed elevated) helps improve lung expansion and ease breathing. This position maximizes the patient's lung capacity and can provide relief from dyspnea.
Choice E rationale:
Assess the pulse oximetry. Rationale: Monitoring pulse oximetry levels is essential in assessing the patient's oxygen saturation. It helps the nurse determine if the patient is receiving adequate oxygenation, which is crucial in managing dyspnea. A normal oxygen saturation range is typically 95% to 100%.
Correct Answer is D
Explanation
Choice A rationale:
Permitting smoking in the home, even with low-flow oxygen, is highly dangerous and increases the risk of fire. Oxygen supports combustion, and any open flames, including smoking materials, can lead to a catastrophic fire. Therefore, this option is incorrect and unsafe.
Choice B rationale:
Placing the oxygen tank in direct sunlight is not advisable. Oxygen tanks should be stored in cool, well-ventilated areas away from direct sunlight, heat sources, and flammable materials. Storing the tank in direct sunlight can increase the pressure inside the tank, potentially leading to leaks or ruptures.
Choice C rationale:
Encouraging the patient to use electric razors is a safe practice when wearing oxygen. Electric razors eliminate the risk of open flames, reducing the potential for accidents. This option promotes patient safety and is a suitable instruction for patients using oxygen at home.
Choice D rationale:
Not using electrical equipment near the oxygen administration set is crucial for patient safety. Electrical equipment can generate sparks, posing a significant fire hazard in the presence of oxygen. Instructing patients to keep electrical devices away from oxygen supplies helps prevent accidents and ensures a safe home environment for patients requiring oxygen therapy.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.
