The nurse is teaching a spouse how to care for a client who recently had a stroke and has residual weakness on the right side. Which style of shoes should the nurse recommend the client wear when ambulating with the spouse's assistance?

Slip-on rubber shower shoes

Tennis shoes with Velcro

Leather-soled loafers

Rubber-soled slippers

Answer and Explanation

The Correct Answer is B

Choice A reason: Slip-on rubber shower shoes are not recommended as they do not provide the necessary support or stability for a client with weakness on one side.

Choice B reason: Tennis shoes with Velcro are ideal as they offer good support and are easy to fasten, which is beneficial for a client with one-sided weakness and potentially limited dexterity.

Choice C reason: Leather-soled loafers can be slippery and do not offer the snug fit and support needed for safe ambulation post-stroke.

Choice D reason: Rubber-soled slippers may provide some grip but typically do not offer the structured support that is necessary for a client with post-stroke weakness.

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Correct Answer is A

Explanation

Choice A reason: If the oxygen saturation remains stable during the procedure, it indicates that the suctioning is not adversely affecting the client's oxygenation, and the nurse can safely continue.

Choice B reason: Applying an oxygen mask is not necessary if the oxygen saturation is stable and within a safe range.

Choice C reason: Repositioning the pulse oximeter clip is only necessary if there is a concern about the accuracy of the reading, not when the reading is stable.

Choice D reason: There is no need to stop suctioning if the oxygen saturation is stable at 94%, as this is within the acceptable range for most clients.

A. Uses normal saline to irrigate the wound. B. Cleans from less soiled to more soiled areas. C. Opens a sterile package towards the body. D. Places soiled dressing in a plastic bag.

Correct Answer is C

Explanation

Choice A reason: Using normal saline to irrigate the wound is a correct practice and does not indicate a need for additional teaching. Normal saline is isotonic and is commonly used for wound irrigation because it does not interfere with the natural healing process.

Choice B reason: Cleaning from less soiled to more soiled areas is also a correct technique to prevent contamination of cleaner areas. This method helps to reduce the risk of infection and is a standard practice in wound care.

Choice C reason: Opening a sterile package towards the body is incorrect and indicates that additional teaching is needed. When opening a sterile package, it should be opened away from the body to maintain the sterility of the contents and prevent contamination.

Choice D reason: Placing soiled dressing in a plastic bag is a proper disposal method and does not indicate a need for additional teaching. It is important to properly dispose of soiled dressings to prevent the spread of infection.

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The nurse is teaching a spouse how to care for a client who recently had a stroke and has residual weakness on the right side. Which style of shoes should the nurse recommend the client wear when ambulating with the spouse's assistance?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

While suctioning a client's nasopharynx, the nurse observes that the client's oxygen saturation remains at 94%, which is the same reading obtained prior to starting the procedure. Which action should the nurse take in response to this finding?

Correct Answer is A

Explanation

A family member is demonstrating wound care using sterile technique. Which action indicates to the nurse that additional teaching is needed?

Correct Answer is C

Explanation

While assisting a client with oral care, the nurse assesses the client's mouth. It is most important for the nurse to take action in response to which finding?

During the admission assessment to the hospital, an adult client reports being allergic to latex, penicillin, and bananas. Which intervention should the nurse implement first?

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When performing blood pressure measurements to assess for orthostatic hypotension, which action should the nurse implement first?

The nurse is teaching a spouse how to care for a client who recently had a stroke and has residual weakness on the right side. Which style of shoes should the nurse recommend the client wear when ambulating with the spouse's assistance?

The nurse is entering prescriptions for laboratory work in a client's electronic medical record (EMR) when the system locks up and does not restart. Which action should the nurse take first?

The nurse notes that a client has cyanosis of the toes and fingertips. Which vital sign should the nurse obtain first?