A client with osteoarthritis of the hips and knees has received instructions on how to use a walker for ambulation.
Which behavior observed by the nurse indicates the client understands the instructions?
The client uses the walker to get up from the chair and looks down at his feet to prevent falling.
The client bears weight on both feet when moving the walker ahead and steps with the weaker leg first.
The client places her full weight on the walker with her arms while taking steps to prevent pressure on her lower extremity joints.
The client leans forward at a 60-degree angle while stepping into the walker but looks ahead at where he is going.
The Correct Answer is B
The client bears weight on both feet when moving the walker ahead and steps with the weaker leg first. This is the proper way to use a walker for ambulation, as it provides stability and reduces stress on the affected joints.
Choice A is wrong because the client should not look down at his feet to prevent falling, but rather look ahead at where he is going. Looking down can cause neck strain and loss of balance.
Choice C is wrong because the client should not place her full weight on the walker with her arms while taking steps, as this can cause upper extremity fatigue and injury. The client should use the walker as a support, not a crutch.
Choice D is wrong because the client should not lean forward at a 60-degree angle while stepping into the walker, as this can cause back pain and poor posture. The client should stand upright and move the walker forward about one step’s length at a time.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
0.8.
To find the answer, you need to use the formula: Dose ordered / Dose available = Volume to administer
In this case, the dose ordered is 250,000 units and the dose available is 300,000 units/mL. So, you need to divide 250,000 by 300,000 and get 0.8333.
Then, you need to round it to one decimal place and get 0.8 mL. Choice A is wrong because it is too low.
If you administer 0.4 mL, you will give only 120,000 units of penicillin G benzathine, which is half of the prescribed dose.
Choice C is wrong because it is too high.
If you administer 1.2 mL, you will give 360,000 units of penicillin G benzathine, which is 44% more than the prescribed dose.
Choice D is wrong because it is also too high.
If you administer 1.6 mL, you will give 480,000 units of penicillin G benzathine, which is almost double the prescribed dose.
The normal range for penicillin G benzathine dosage depends on the type and severity of infection, but it is usually between 50,000 and 2.4 million units per injection.
Correct Answer is D
Explanation
Ineffective Airway Clearance. This is because a client with a Glasgow Coma Scale (GCS) of 6 has a severe impairment of consciousness and is at risk of aspiration, respiratory failure, and infection. The GCS is a clinical scale that measures a person’s level of consciousness after a brain injury based on their eye, verbal and motor responses. A GCS score of 6 indicates that the client only opens eyes to pain, makes incomprehensible sounds and shows abnormal flexion to pain.
Choice A is wrong because Acute Confusion is not a priority nursing diagnosis for a client with a GCS of 6.
Acute Confusion is a state of disorientation and impaired memory that can be caused by various factors such as medication, infection, electrolyte imbalance or dementia.
A client with a GCS of 6 is not likely to be confused, but rather unresponsive or minimally responsive.
Choice B is wrong because Self-Care Deficit is not a priority nursing diagnosis for a client with a GCS of 6.
Self-care deficit is the impaired ability to perform activities of daily living such as bathing, dressing, feeding or toileting.
A client with a GCS of 6 will need assistance with all these activities, but the most urgent concern is their airway patency and oxygenation.
Choice C is wrong because Risk for Impaired Skin Integrity is not a priority nursing diagnosis for a client with a GCS of 6.
Risk for Impaired Skin Integrity is the potential for damage to the skin or underlying tissues due to pressure, friction, shear or moisture.
A client with a GCS of 6 may be at risk for developing pressure ulcers or skin breakdown due to immobility and reduced sensation, but this is not as life-threatening as ineffective airway clearance.
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