A nurse at an extended-care facility is instructing a class of assistive personnel (AP) about the use of assistive devices during client ambulation.
Which of the following instructions should the nurse include about assisting clients who use a cane?

“The client should first move the strong leg then the weak one.”.

“When the client moves, he should move the cane forward first.”.

“The client should hold the cane on the weak side of his body.”.

“The grip should be level with the client’s waist.”. .

Answer and Explanation

The Correct Answer is B

Choice A rationale

The statement “The client should first move the strong leg then the weak one” is not the best practice when using a cane. The client should move the cane and the weak leg forward at the same time, then move the strong leg.
Choice B rationale
The statement “When the client moves, he should move the cane forward first” is the correct practice. Moving the cane first provides stability and support for the next step.
Choice C rationale
The statement “The client should hold the cane on the weak side of his body” is not the correct practice. The cane should be held on the strong side of the body to provide support for the weak side.
Choice D rationale
The statement “The grip should be level with the client’s waist” is a good practice, but it’s not the best answer for this question. The grip of the cane should be at the level of the client’s wrist when the client’s arm is hanging down. This allows the client to maintain a slight bend in their elbow when holding the cane.

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Correct Answer is C

Explanation

Choice A rationale
Antimicrobial dressings are typically used for wounds that are infected or at high risk of infection. A stage I pressure ulcer, which involves intact skin with non-blanchable redness, would not typically require an antimicrobial dressing.
Choice B rationale
Wet-to-dry dressings are used for mechanical debridement of wounds with necrotic tissue. A stage I pressure ulcer does not involve necrotic tissue, so this type of dressing would not be appropriate.
Choice C rationale
Transparent dressings are often used for stage I pressure ulcers. They provide a protective layer over the wound, promoting a moist environment and facilitating the healing process.
Choice D rationale

Dry, sterile dressings are typically used for wounds that need to be kept dry. A stage I pressure ulcer benefits from a moist healing environment, which can be provided by a transparent dressing.

A. 28% B. 70% C. 509% D. 36% .

Correct Answer is A

Explanation

The correct answer is Choice A. The client is receiving an oxygen concentration of 28%. Nasal cannulas can deliver oxygen at a flow rate ranging from 1 to 6 liters per minute (L/min), with

each additional liter increasing the fraction of inspired oxygen (FiO2) by 4%. Therefore, at 2 L/min, the client is receiving an oxygen concentration of 28%78.

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A nurse at an extended-care facility is instructing a class of assistive personnel (AP) about the use of assistive devices during client ambulation. Which of the following instructions should the nurse include about assisting clients who use a cane?

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Naxlex Comprehensive Predictor Exams

A nurse is performing wound care for an older adult patient who has a stage I pressure ulcer. Which of the following types of dressings should the nurse apply to the wound?

Correct Answer is C

Explanation

A client is receiving oxygen at 2 L/min via a nasal cannula. What oxygen concentration is the client receiving?

Correct Answer is A

Explanation

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A nurse at an extended-care facility is instructing a class of assistive personnel (AP) about the use of assistive devices during client ambulation.
Which of the following instructions should the nurse include about assisting clients who use a cane?