Nokea
A nurse is reinforcing teaching with a client about the use of a quad cane. Which of the following statements by the client indicates an understanding of the teaching?
- A. I should wear shoes with smooth soles to help slide my weak leg forward.
- B. I should move my stronger leg forward before moving my weaker leg.
- C. I will move the cane forward 18 inches.
- D. I will hold the cane on my stronger side.
Correct Answer: B
Rationale: Moving the stronger leg first is correct for safe ambulation with a quad cane.
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A nurse is providing end-of-life care to a client who is experiencing dyspnea. Which of the following actions should the nurse take?
- A. Provide oral care to the client once every 8 hr.
- B. Use a fan to circulate air in the client's room.
- C. Reposition the client once every 4 hr.
- D. Place the head of the client's bed flat.
Correct Answer: B
Rationale: A fan circulates air, relieving dyspnea by enhancing the feeling of airflow.
A nurse is reinforcing teaching with a client who has crutches regarding the use of the three-point gait. Which of the following instructions should the nurse include?
- A. Bear weight on the unaffected leg.
- B. Stand with the crutch tips against the feet.
- C. Hold the arms straight when walking.
- D. Keep the crutches at the level of the axillae.
Correct Answer: A
Rationale: In the three-point gait, weight is borne on the unaffected leg while moving crutches and the affected leg together.
A nurse is preparing to provide tracheostomy care to a client who has a chronic tracheostomy. In which order should the nurse complete the following steps?
- A. Scrub the inside and outside of the inner cannula with a small brush.
- B. Wipe the inside of the inner cannula with a folded pipe cleaner.
- C. Cleanse the stoma site with 0.9% sodium chloride solution.
- D. Unlock and remove the inner cannula.
- E. Pour 2.54 cm (1 in) of 0.9% sodium chloride solution into the sterile basin.
Correct Answer: E,D,A,B,C
Rationale: E: Prepare solution. D: Remove cannula. A: Scrub cannula. B: Wipe cannula. C: Cleanse stoma maintains sterility.
A nurse is caring for a client who requires a sterile dressing change. The nurse should recognize that the surgical field has been contaminated if which of the following actions occur?
- A. The sterile solution is poured with the bottle held over the field.
- B. Unnecessary sterile items are placed on the field.
- C. A pair of sterile forceps is allowed to rest in a container of sterile water on the field.
- D. The handle of a pair of sterile scissors is resting 5 cm (2 in) from the field's edge.
Correct Answer: A
Rationale: Pouring solution with the bottle over the field risks contamination from touch or splash.
A nurse is reinforcing teaching with a client who is perimenopausal. Which of the following statements by the client indicates an understanding of the teaching?
- A. The best time to perform a breast self-examination is on the first day of my period.
- B. I can expect to have regular periods until I am in menopause.
- C. I might have headaches due to a decline in my estrogen levels.
- D. I should stop receiving Papanicolaou tests once I reach menopause.
Correct Answer: C
Rationale: Declining estrogen levels during perimenopause can cause headaches.