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.

Answer and Explanation

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.

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Correct Answer is C

Explanation

The nurse refuses to care for someone who reminds her of a family member after interviewing the client upon admission. This action is not appropriate in the prevention of liability because it violates the client’s right to receive care and may be considered as discrimination or abandonment. The nurse has a duty to provide care to all clients regardless of their personal feelings or preferences.

Choice A is wrong because establishing rapport with the client in an inpatient psychiatric setting is an appropriate action to prevent liability. It helps to build trust and communication between the nurse and the client and reduces the risk of misunderstanding or conflict.

Choice B is wrong because documenting accurately and honestly in the electronic health record is an appropriate action to prevent liability. It provides evidence of the care provided, the client’s condition and response, and any incidents or complications that occurred.

Choice D is wrong because referring to the policy of the inpatient psychiatric setting when uncertain of a standard of care is an appropriate action to prevent liability. It helps the nurse to follow the best practices and guidelines for providing safe and effective care to the client.

A. Offering the client a bedpan every three hours. B. Keeping an emesis basin near the bedside. C. Providing oral care every four hours. D. Changing the bed linens frequently.

Correct Answer is D

Explanation

This is because a client who has been diaphoretic for the past six hours is likely to have wet and uncomfortable bed linens that can cause skin breakdown and infection. Changing the bed linens frequently can help keep the client dry and comfortable.

Choice A is wrong because offering the client a bedpan every three hours is not related to diaphoresis.

The client may or may not need to use the bedpan depending on their fluid intake and output.

Choice B is wrong because keeping an emesis basin near the bedside is not related to diaphoresis.

The client may or may not need to vomit depending on their underlying condition.

Choice C is wrong because providing oral care every four hours is not enough for a client who has been diaphoretic for the past six hours. The client may have dry mouth and dehydration due to excessive sweating and may need more frequent oral care and hydration.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse takes actions to avoid liability when caring for a client with a psychiatric disorder. Which action is not appropriate in the prevention of liability?

Correct Answer is C

Explanation

Which intervention should the nurse include while caring for a client who has been diaphoretic for the past six hours?

Correct Answer is D

Explanation

Which amount of urine production should the nurse evaluate as adequate output for a typical adult client?

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A nurse identifies that a medication is ordered for the client as twice the regular dosage. What action should the nurse take?

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?