Nokea
The nurse is observing a client ambulate with a walker. It would require follow-up by the nurse if the client
- A. Advances the walker 6-10 inches.
- B. Has their elbow flexed 15-30 degrees.
- C. Tilts the walker forward to help stand up from a chair.
- D. Advances the walker and then the affected leg.
Correct Answer: C
Rationale: Tilting the walker forward to stand is unsafe, risking falls. Advancing 6-10 inches, 15-30 degree elbow flexion, and proper stepping sequence are correct.
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The home health nurse is caring for a 67-year-old female client with progressive multiple sclerosis.
Item 5 of 6
Current Medications
Nurses' Notes
• cephalexin 500 mg p.o. every six hours for 10 days
• diazepam 5 mg p.o. daily PRN muscle spasm
• multivitamin 1 tablet daily
• ergocalciferol 10,000 international units p.o. Daily
Which of the following instructions should the nurse include when teaching the client how to ambulate with a walker? Select all that apply.
- A. The top of the walker should line up with your wrist crease.
- B. Lean over the walker to maintain good balance.
- C. When going up the stairs, advance the walker up onto the step first.
- D. When getting up from a chair, use the chair's armrests to push yourself up.
- E. Move the walker forward 2 to 4 inches with each step.
Correct Answer: A,D
Rationale: The walker should align with the wrist crease for proper height, and using chair armrests ensures safe standing. Leaning over the walker risks imbalance, and the walker follows the stronger leg on stairs.
The nurse is planning a staff development conference about ways to prevent the transmission of the hepatitis C virus to healthcare workers. It would be appropriate for the nurse to cover which topic?
- A. How to obtain the HCV vaccine
- B. How to dispose of sharps safely
- C. How to dispose of urine and feces for those with HCV
- D. Isolation precautions for individuals with HCV
Correct Answer: B
Rationale: Safe sharps disposal prevents needlestick injuries, a primary transmission route for HCV. No vaccine exists, and urine/feces disposal or isolation are less relevant.
The nurse is preparing a client scheduled for hip arthroplasty in two hours. The nurse has received a prescription for tranexamic acid. The nurse understands that this medication has had a therapeutic effect when the client has
- A. decreased postoperative pain
- B. increased postoperative vital capacity
- C. less postoperative blood loss
- D. no surgical site infection
Correct Answer: C
Rationale: Tranexamic acid is an antifibrinolytic that reduces bleeding by inhibiting clot breakdown. Its therapeutic effect is evident with less postoperative blood loss. It does not directly affect pain, vital capacity, or infection rates.
The nurse is caring for a client with a tracheostomy. Which of the following items is essential to have at the bedside?
- A. Air humidifier
- B. Inner cannula
- C. Nasal cannula oxygen
- D. Tracheostomy brush
Correct Answer: B
Rationale: An inner cannula is essential for tracheostomy care to replace or clean it if obstructed. Humidifiers, nasal cannulas, and brushes are not critical bedside items.
The nurse is assessing a client who had gastric bypass surgery two days ago. The nurse should prioritize assessing the client for
- A. venous thromboembolism
- B. their current weight
- C. nausea and vomiting
- D. surgical site infection
Correct Answer: C
Rationale: Nausea and vomiting are priority assessments post-gastric bypass due to the risk of anastomotic leaks or obstruction, which can be life-threatening. Venous thromboembolism and surgical site infection are concerns but less immediate, and weight assessment is not a priority at this stage.