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 D

Explanation

Choice A rationale
Tachycardia is not a common adverse effect of oxygen therapy. It is more likely to be associated with conditions such as fever, anemia, or hypoxia.
Choice B rationale
Poor skin turgor is a sign of dehydration, not a typical adverse effect of oxygen therapy. Oxygen therapy does not directly affect the body’s hydration status.
Choice C rationale
Excessive pulmonary secretions are not a direct adverse effect of oxygen therapy. Conditions such as pneumonia or bronchitis often cause increased secretions.

Choice D rationale
Cracks in the oral mucous membranes can occur as a result of oxygen therapy. Oxygen can dry out the mucous membranes, leading to discomfort and potential cracking.

A. There is slough on part of the wound area. B. There appears to be persistent reddening of the skin. C. There is full-thickness skin loss with a crater. D. There is a fluid-filled area under the skin.

Correct Answer is C

Explanation

Choice A rationale
Slough, which is a layer of yellowish, dead tissue that can develop on the surface of a wound, is not a defining characteristic of a stage 3 pressure ulcer.
Choice B rationale
Persistent reddening of the skin is typically associated with a stage 1 pressure ulcer, not a stage 3. In a stage 1 pressure ulcer, the skin remains intact but may be red and may not blanch (lose color briefly) when you press your finger on it.
Choice C rationale
A stage 3 pressure ulcer involves full-thickness skin loss that appears as a deep crater. The ulcer may extend into the subcutaneous tissue layer, but not through it to the underlying

muscle or bone. This description matches the statement in Choice C, making it the correct answer.
Choice D rationale
A fluid-filled area under the skin could potentially indicate a blister or a stage 2 pressure ulcer, not a stage 3. In a stage 2 pressure ulcer, the outer layer of skin (epidermis) and part of the underlying layer of skin (dermis) are damaged or lost.

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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 patient with pneumonia who has been on oxygen therapy for several days. Which of the following symptoms should the nurse recognize as a potential adverse effect of oxygen therapy?

Correct Answer is D

Explanation

Upon inspecting a client’s skin, a nurse identifies a stage 3 pressure ulcer on the sacrum. Which statement best describes a stage 3 pressure ulcer?

Correct Answer is C

Explanation

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