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A nurse is evaluating a client's use of a cane. Which of the following actions should the nurse identify as an indication of correct use?
- A. The top of the cane is parallel to the client's wrist.
- B. When walking
- C. the client moves the cane 46 cm (18 in) forward.
- D. The client holds the cane on the stronger side of her body.
- E. The client moves her stronger limb forward with the cane.
Correct Answer: D
Rationale: Correct Answer: D: The client holds the cane on the stronger side of her body.
Rationale:
1. Holding the cane on the stronger side provides better stability and support.
2. This position allows the client to shift weight onto the cane during walking.
3. It helps to reduce pressure on the weaker side, promoting balance and preventing falls.
Incorrect Choices:
A: The top of the cane parallel to the client's wrist is not directly related to correct use.
B: Walking is a general action, not specific to correct cane use.
C: Specific measurements of cane movement are not essential for correct use.
E: Moving the stronger limb forward with the cane does not ensure proper use.
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A nurse is caring for a client who is postoperative and refuses to use an incentive spirometer following major abdominal surgery. Which of the following actions is the nurse's priority?
- A. Request that a respiratory therapist discuss the technique for incentive spirometry with the client.
- B. Determine the reasons why the client is refusing to use the incentive spirometer.
- C. Document the client's refusal to participate in health restorative activities.
- D. Administer a pain medication to the client.
Correct Answer: B
Rationale: The correct answer is B: Determine the reasons why the client is refusing to use the incentive spirometer. The nurse's priority is to assess why the client is refusing the treatment to address the underlying issue. By understanding the client's reasoning, the nurse can provide appropriate interventions and education to encourage compliance, ensuring optimal recovery. Requesting a respiratory therapist (A) may be helpful but does not address the client's refusal directly. Documenting the refusal (C) is important but does not actively address the issue. Administering pain medication (D) may provide temporary relief but doesn't address the root cause of refusal.
A nurse on a medical-surgical unit is caring for a client who has a new prescription for wrist restraints. Which of the following actions should the nurse take?
- A. Pad the client's wrist before applying the restraints.
- B. Evaluate the client's circulation every 8 hr after application.
- C. Remove the restraints every 4 hr to evaluate the client's status.
- D. Secure the restraint ties to the bed's side rails.
Correct Answer: A
Rationale: The correct answer is A: Pad the client's wrist before applying the restraints. This is important to prevent pressure injuries and ensure the client's comfort and safety. Padding helps distribute pressure and reduces the risk of skin breakdown. Choices B, C, and D are incorrect. B is not recommended as it is essential to monitor circulation frequently, not just every 8 hours. C is incorrect because restraints should not be removed without a valid reason due to the risk of injury or harm to the client. D is also wrong as restraints should be secured to parts of the bed frame, not side rails, to prevent the client from using them to injure themselves or others.
A nurse is caring for a client who has dementia. Which of the following interventions should the nurse take to minimize the risk for injury to the client?
- A. Use a bed exit alarm system.
- B. Raise four side rails while the client is in bed.
- C. Apply one soft wrist restraint.
- D. Dim the lights in the client's room.
Correct Answer: A
Rationale: The correct answer is A: Use a bed exit alarm system. This intervention is crucial in minimizing the risk of injury for a client with dementia as it alerts the nurse when the client attempts to get out of bed, preventing falls. This approach promotes client safety by allowing timely intervention. Raising four side rails (B) may restrict the client's movement and cause agitation or attempts to climb over the rails, increasing the risk of injury. Applying a soft wrist restraint (C) is considered a restrictive measure and should be avoided unless absolutely necessary due to the risk of causing emotional distress and physical harm to the client. Dimming the lights (D) in the client's room may increase confusion and disorientation, leading to a higher risk of falls.
A nurse in a long-term care facility is caring for a client who dies during the nurse's shift. Identify the sequence in which the nurse should perform the following steps. (Move the steps into the box on the right, placing them in the order of performance. Use all the steps.)
- A. Place a name tag on the body.
- B. Obtain the pronouncement of death from the provider.
- C. Remove tubes and indwelling lines.
- D. Wash the client's body.
- E. Ask the client's family members if they would like to view the body.
Correct Answer: B, E, C, D, A
Rationale: 1. Obtain the pronouncement of death from the provider (B): This is the first step to officially confirm the client's passing.
2. Ask the client's family members if they would like to view the body (E): Providing support to the family is crucial.
3. Remove tubes and indwelling lines (C): This step is necessary to prepare the body for respectful handling.
4. Wash the client's body (D): Maintaining dignity and cleanliness is important.
5. Place a name tag on the body (A): This ensures proper identification for all involved.
In summary, obtaining the pronouncement of death is the priority, followed by addressing the emotional needs of the family, preparing the body, and ensuring proper identification. Removing tubes and washing the body come before placing the name tag.
A nurse is reviewing a client's fluid and electrolyte status. Which of the following findings should the nurse report to the provider?
- A. Sodium 130 mEq/L
- B. Creatinine 1.0 mg/dL
- C. Sodium 135 mEq/L
- D. Potassium 5.4 mEq/L
Correct Answer: A
Rationale: The correct answer is A: Sodium 130 mEq/L. A sodium level of 130 mEq/L is considered hyponatremia, which can indicate potential fluid imbalance or certain health conditions. The nurse should report this finding to the provider for further evaluation and intervention.
Choices B, C, and D fall within normal reference ranges for creatinine, sodium, and potassium levels, respectively. Therefore, they do not require immediate reporting.
In summary, the nurse should report a low sodium level (A) as it can be clinically significant, while the other choices are within normal limits and do not warrant immediate action.