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","C","E"]

Explanation

Choice A rationale
Checking that the client’s restraints are secured with a half-bow knot is a good practice. This type of knot is secure but can be easily untied, which is important for quick removal of the restraints if necessary.
Choice B rationale
Requesting that the provider prescribe the restraints as PRN is not a good practice. Restraints should only be used as a last resort and must be ordered by a healthcare provider. The order must specify the reason for the restraints and the duration of use.
Choice C rationale
Ensuring that the client’s wrists are padded is a good practice. Padding helps to prevent skin breakdown and nerve damage.
Choice D rationale
Loosening the restraints once every 4 hours is not a good practice. Restraints should be removed or loosened every 2 hours to allow for skin care and assessment, range of motion exercises, and to check for signs of injury.
Choice E rationale

Documenting client care every 15 minutes is a good practice. This includes documenting the client’s behavior, the type and location of restraints, the frequency of care (at least every 2 hours), and the client’s response to the restraints.

A. It allows you to remove it for a while when it gets uncomfortable. B. It delivers the low concentration of oxygen you need. C. It delivers a specific concentration of oxygen constantly. D. It delivers the highest concentration of oxygen possible.

Correct Answer is B

Explanation

Choice A rationale
While it’s true that a nasal cannula allows the patient to remove it for a while when it gets uncomfortable, this is not the primary reason for using a nasal cannula. The main purpose of a nasal cannula is to deliver oxygen.
Choice B rationale
A nasal cannula delivers the low concentration of oxygen that the patient needs. It is designed to provide a specific amount of oxygen, and the flow rate can be adjusted as needed.

Choice C rationale
While a nasal cannula does deliver a specific concentration of oxygen, it does not do so constantly. The amount of oxygen delivered can vary depending on the patient’s breathing rate and depth.
Choice D rationale
A nasal cannula does not deliver the highest concentration of oxygen possible. Other devices, such as non-rebreather masks, can deliver higher concentrations of oxygen.

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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 is caring for a client who is confused and has been placed in wrist restraints. Which of the following actions should the nurse take while caring for this client? (Select all that apply.)

Correct Answer is ["A","C","E"]

Explanation

A patient is undergoing oxygen therapy through a nasal cannula.If the patient inquires about the reason for having oxygen tubing in their nose, what explanation about the cannula should the nurse provide?

Correct Answer is B

Explanation

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