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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason: Discussing the prescription with the provider is critical, as amoxicillin, a penicillin derivative, is contraindicated in clients with penicillin allergies due to risk of anaphylaxis. This ensures patient safety by verifying or correcting the order, aligning with nursing advocacy and safety protocols, making it correct.
Choice B reason: Administering amoxicillin to a client with a penicillin allergy risks severe allergic reactions, including anaphylaxis, violating patient safety principles. Nurses must verify contraindicated orders before administration, making this action dangerous and incorrect in this scenario.
Choice C reason: Placing an incident report is premature, as no error has occurred yet. The nurse’s role is to prevent harm by addressing the contraindicated prescription proactively. This action does not resolve the issue and is inappropriate as the first step, making it incorrect.
Choice D reason: Calling the pharmacist for clarification is less direct than discussing with the provider, who issued the order. While pharmacists can provide guidance, the provider must confirm or change the prescription to ensure safety, making this action secondary and less effective.
Correct Answer is B
Explanation
Choice A reason: Preparing for a paracentesis is inappropriate, as abdominal distention post-laparoscopic cholecystectomy is typically due to retained carbon dioxide from insufflation, not ascites. Paracentesis is invasive and unnecessary, risking complications without addressing the cause, making it an incorrect intervention for this scenario.
Choice B reason: Assisting the client to ambulate promotes the expulsion of residual gas used during laparoscopic cholecystectomy, relieving abdominal distention. Early mobility enhances circulation, reduces bloating, and prevents complications like ileus, aligning with postoperative care guidelines, making it the most effective and appropriate action.
Choice C reason: Inserting a rectal suppository is not indicated, as distention is likely from gas, not constipation, immediately post-cholecystectomy. Suppositories may cause discomfort without resolving gas-related bloating. This intervention is premature and misaligned with the cause, making it inappropriate.
Choice D reason: Placing the client in the prone position may worsen discomfort from abdominal distention by compressing the abdomen, trapping gas. Upright or walking positions facilitate gas movement and relief. This position is counterproductive, making it an incorrect choice for managing post-surgical distention.
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