A charge nurse is supervising a newly hired nurse who is instructing a client about how to use a walker. For which of the following actions should the charge nurse intervene?

The client advances the walker and takes a step towards it.

The client takes multiple steps while holding the walker.

The client grasps the walker by the hand grips on the upper bars.

The client lifts the walker as it is moved forward.

Answer and Explanation

The Correct Answer is B

Choice A reason: Advancing the walker and taking a step towards it is the correct technique, ensuring stability by moving the walker first, then stepping. This maintains balance and prevents falls, aligning with safe walker use protocols, so no intervention is needed for this action.
Choice B reason: Taking multiple steps while holding the walker compromises stability, as the walker must be repositioned after each step to ensure support. This increases fall risk, requiring the charge nurse to intervene to correct the technique and ensure the client’s safety during ambulation.
Choice C reason: Grasping the walker by the hand grips on the upper bars is correct, as it provides optimal control and balance. This standard technique supports safe mobility, and no intervention is required, as it adheres to proper walker use guidelines.
Choice D reason: Lifting the walker as it is moved forward is acceptable for lightweight or rolling walkers, depending on the client’s strength and model. While sliding is preferred for standard walkers, lifting is not inherently unsafe, so intervention is unnecessary unless improper execution is observed.

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Correct Answer is C

Explanation

A. Maternal fever Maternal fever typically causes fetal tachycardia (elevated baseline >160/min), not bradycardia. Fever increases maternal metabolic rate and fetal heart rate.
B. Chorioamnionitis This intrauterine infection also leads to fetal tachycardia, due to inflammatory stress and maternal fever. It is not a cause of bradycardia.
C. Maternal hypoglycemia ✅ Low maternal glucose levels can reduce fetal energy supply and oxygenation, leading to fetal bradycardia (baseline <110/min). This is a recognized cause of sustained bradycardia.
D. Fetal anemia Fetal anemia usually results in tachycardia as the fetus compensates for reduced oxygen‑carrying capacity by increasing heart rate. It does not cause bradycardia.

A. Monitor for hypernatremia. B. Assess for fluid overload. C. Check for hypoglycemia. D. Evaluate for dehydration.

Correct Answer is B

Explanation

Choice A reason: Hypernatremia is unlikely with 0.45% sodium chloride, a hypotonic solution that dilutes serum sodium. Over-infusion risks hyponatremia, not high sodium levels. Monitoring for hypernatremia is inappropriate, as the solution’s low sodium content does not contribute to elevated sodium in fluid therapy.
Choice B reason: Assessing for fluid overload is essential, as 0.45% sodium chloride, being hypotonic, can cause water to shift into cells, risking pulmonary or cerebral edema. This is critical in clients with renal or cardiac issues, where monitoring for dyspnea or swelling ensures safe fluid administration.
Choice C reason: Hypoglycemia is not directly linked to 0.45% sodium chloride, which affects fluid and electrolytes, not glucose. Fluid shifts may indirectly stress metabolism, but hypoglycemia relates to fasting or insulin issues, making this an inappropriate focus for monitoring in this fluid therapy context.
Choice D reason: Dehydration is unlikely, as 0.45% sodium chloride provides free water, promoting hydration. It corrects hypernatremia or replaces fluid losses. Evaluating for dehydration is unnecessary unless infusion is inadequate or losses persist, which is not indicated in the context of this hypotonic solution.

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A charge nurse is supervising a newly hired nurse who is instructing a client about how to use a walker. For which of the following actions should the charge nurse intervene?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is B

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