Which of the following instruction should a nurse provide to promote the safe use of a cane as an assistive device for a client who is recovering from a musculoskeletal injury of the right lower extremity?

Hold the cane on the left side.

Place the cane 46 cm (18 in) in front of her feet before advancing.

Adjust the height of the cane so the arm is straight during use.

Remove the rubber tip from the end of the cane.

Answer and Explanation

The Correct Answer is A

A. Hold the cane on the left side: The cane should be held on the stronger (unaffected) side (in this case, the left) to provide balance and support for the injured right leg.
B. Place the cane 46 cm (18 in) in front of her feet before advancing: The cane should only be placed about 15–25 cm (6–10 in) in front to maintain stability.
C. Adjust the height of the cane so the arm is straight during use: The elbow should be slightly flexed (~20–30 degrees) for optimal balance and comfort.
D. Remove the rubber tip from the end of the cane: The rubber tip is essential for traction and to prevent slipping.

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Correct Answer is C

Explanation

A. Raise the height of the client's bed: Raising the bed too high can increase the risk of falls. The bed should be at a safe working height for the nurse and low enough for the client to place their feet on the floor.
B. Place the chair at a 90° angle to the bed: The chair should be placed at a 45° angle to the bed on the client's strong side (right side in this case) to make the transfer easier.
C. Lock the wheels on the client's bed: This ensures stability during the transfer and prevents the bed from moving, reducing the risk of falls or injury.
D. Place the chair on the client's left side: Since the client has left-sided weakness, the chair should be placed on the right (strong) side to facilitate a safer and easier transfer.

A. Alias B. Medical condition C. Telephone number D. Room number

Correct Answer is C

Explanation

A. Alias: Aliases are not unique or legally sufficient for client identification.
B. Medical condition: This is not a unique or secure way to identify a client.
C. Telephone number: Per The Joint Commission guidelines, acceptable client identifiers include full name, birthdate, and a unique identifier such as telephone number or medical record number.
D. Room number: Room numbers are not unique and can change during a hospital stay.

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Which of the following instruction should a nurse provide to promote the safe use of a cane as an assistive device for a client who is recovering from a musculoskeletal injury of the right lower extremity?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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