Nokea
The nurse assists a client with left-sided weakness. Which of the following actions should the nurse perform when assisting this client in ambulating with a cane? Select all that apply.
- A. Place a gait belt around the client's waist.
- B. Stand on the client's left side during ambulation.
- C. Instruct the client to put the cane in the left hand.
- D. Measure the cane from the client's wrist crease.
- E. Instruct the client to put the cane in the right hand.
- F. Instruct the client to look down while ambulating.
Correct Answer: A,B,E
Rationale: A gait belt ensures safety, standing on the weaker side provides support, and the cane in the right hand aids balance. Cane height is measured to the greater trochanter, and looking down risks falls.
You may also like to solve these questions
The first bodily area to be washed during a complete bed bath is the:
- A. Inner canthus of the eye
- B. Cheeks
- C. Forehead
- D. Chin
Correct Answer: A
Rationale: Washing from the inner canthus of the eye outward prevents debris spread and is the starting point for a bed bath. Other areas follow.
The right brake on your client's wheelchair is not holding as strongly as the left brake. What is the priority action?
- A. Ask the client if this happened today.
- B. Immediately remove the wheelchair from use.
- C. Try to tighten the brake with a simple tool.
- D. Call the physical therapist for another wheelchair.
Correct Answer: B
Rationale: Removing the wheelchair from use is the priority to prevent falls or injuries due to malfunction.
The nurse observes a client perform isometric exercises. It would indicate effective understanding if the client
- A. Exercises both extremities simultaneously.
- B. Knows their heart rate should be monitored while exercising.
- C. Practices forced resistance against stable objects.
- D. Swings their limbs through the full range of motion.
Correct Answer: C
Rationale: Isometric exercises involve static muscle contraction against resistance, like pushing against a stable object. Simultaneous exercise, heart rate monitoring, and full range of motion are not specific to isometrics.
The nurse is caring for a child immediately post-operative following a tonsillectomy. Which assessment finding requires immediate follow-up?
- A. Discomfort while speaking
- B. Frequent swallowing
- C. Drowsiness
- D. Pain with occasional coughing
Correct Answer: B
Rationale: Frequent swallowing in a post-tonsillectomy child may indicate bleeding in the throat, as the child swallows blood, requiring immediate follow-up to prevent hemorrhage. Discomfort, drowsiness, and pain with coughing are expected findings and less urgent.
The emergency department (ED) charge nurse is preparing for a surge of clients diagnosed with Ebola virus disease (EVD). The nurse should plan to take which action? Select all that apply.
- A. Implement visitor restrictions for affected clients
- B. Log entry and exit of all healthcare workers who provide care
- C. Ensure that bleach disinfectant wipes are available in each room
- D. Provide reusable personal protective equipment
- E. Have an observer for donning and doffing of personal protective equipment
Correct Answer: A,B,E
Rationale: Visitor restrictions, logging healthcare worker movements, and an observer for PPE donning/doffing are critical for EVD control. Bleach wipes are insufficient, and reusable PPE is not recommended.