A nurse is assisting an older adult client in the hallway for the first time since admission. The client has brought a standard walker from home.To ensure the client’s safety and proper use of the walker, which of the following actions should the nurse take?

Check that the client lifts the walker and then places it down in front of her.

Walk in front of the client to guide her in moving the walker.

Have the client move one leg forward with the walker.

Make sure that the upper bar of the walker is level with the client’s waist.

Answer and Explanation

The Correct Answer is A

Choice A rationale

The client should lift the walker and place it down in front of her. This is because lifting the walker provides stability and support as the client moves. It’s important for the client to move the walker first, then step forward to ensure balance and prevent falls.
Choice B rationale
Walking in front of the client to guide her in moving the walker is not the best practice. The client should be allowed to set the pace and the nurse should be beside or slightly behind the client to provide assistance if needed.
Choice C rationale
Having the client move one leg forward with the walker is not the most effective way to use a walker. Both legs should move forward after the walker has been placed down in front of the client.
Choice D rationale
Making sure that the upper bar of the walker is level with the client’s waist is a good practice, but it’s not the best answer for this question. The height of the walker should be adjusted so that the handles are at the level of the client’s wrists when the client’s arms are hanging down. This allows the client to maintain a slight bend in their elbows when holding the handles.

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Correct Answer is A

Explanation

Choice A rationale
Turning the patient on their side before starting oral care is a recommended practice when caring for an unresponsive patient. This position helps prevent aspiration, which can occur if the patient cannot swallow properly.
Choice B rationale
Applying petroleum jelly to the patient’s lips after oral care can help prevent dryness and cracking. However, it’s not the primary action the nurse should take when performing oral hygiene for an unresponsive patient.
Choice C rationale
Using the thumb and index finger to keep the patient’s mouth open is not recommended. It can cause discomfort and potential injury to the patient.
Choice D rationale
Using a stiff toothbrush to clean the patient’s teeth is not recommended. A soft toothbrush is usually used to clean the teeth of an unresponsive patient to prevent damage to the gums.

A. Call the family and ask them to make arrangements for someone to sit with the client. B. Obtain a prescription for medication to sedate the client. C. Check the client for injuries. D. Assist the client back into bed and apply restraints.

Correct Answer is C

Explanation

Choice A rationale

While involving the family in the care of an older adult client is important, calling the family to make arrangements for someone to sit with the client is not the immediate action the nurse should take. The nurse’s first responsibility is to ensure the client’s safety and well-being.
Choice B rationale
Obtaining a prescription for medication to sedate the client is not the immediate action the nurse should take. Sedating the client does not address the immediate concern of potential injury.
Choice C rationale
The nurse should first check the client for injuries. This is the immediate action because the client may have sustained injuries from the fall. The nurse should perform a thorough assessment to determine the extent of any injuries and provide appropriate care.
Choice D rationale
Assisting the client back into bed and applying restraints is not the immediate action the nurse should take. Restraints should be used as a last resort and only if less restrictive measures have been ineffective. Furthermore, restraints require a physician’s order.

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A nurse is assisting an older adult client in the hallway for the first time since admission. The client has brought a standard walker from home.To ensure the client’s safety and proper use of the walker, which of the following actions should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse in a long-term care facility is taking care of a patient who is unresponsive. What action should the nurse take when performing oral hygiene for the patient?

Correct Answer is A

Explanation

A nurse in a long-term care facility finds an older adult client lying on the floor next to the bed. What action should the nurse take?

Correct Answer is C

Explanation

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