A nurse is assisting an older adult client who sometimes loses their balance while walking. Which of the following devices is most important for the nurse to use when helping the client ambulate?

Powered stand assist

Cane

Gait belt

Four wheel walker

Answer and Explanation

The Correct Answer is C

A. Powered stand assist: Powered stand assist devices are used for clients who cannot bear weight independently, not for balance issues during ambulation.

B. Cane: A cane provides minimal support and is best for clients with mild weakness, not for those with frequent balance loss.

C. Gait belt: A gait belt provides stability and support while allowing the nurse to assist the client safely if they begin to lose balance.

D. Four-wheel walker: A four-wheel walker rolls easily, which may increase fall risk in a client with balance issues. A standard walker (without wheels) would be safer in some cases.

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Correct Answer is B

Explanation

A. Output assessment: Liquid stool and gas output are expected findings for an ileostomy.

B. General status: The patient’s avoidance of looking at the ileostomy suggests poor adaptation and possible psychological distress, which may require intervention.

C. Stoma assessment: A red, moist, and protruding stoma is a normal finding.

D. Laboratory data: The patient’s potassium level is on the lower end but still within normal limits. There are no critical abnormalities.

A. Straight catheter. B. Indwelling urethral catheter C. Suprapubic catheter D. Intermittent urethral catheter

Correct Answer is C

Explanation

A. Straight catheter: A straight catheter is used for intermittent catheterization and cannot bypass a complete obstruction.

B. Indwelling urethral catheter: A urethral catheter may not be able to pass through a completely obstructed urethra.

C. Suprapubic catheter: A suprapubic catheter is placed directly into the bladder through the abdominal wall, bypassing the obstructed urethra, making it the best option for this client.

D. Intermittent urethral catheter: Like a straight catheter, an intermittent urethral catheter will not work if the urethra is completely obstructed.

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Stoma Assessment	Stoma is protruding 2cm, is red and moist. Peristomal area is clean and intact.
Output	Liquid stool that is malodorous. Gas present in the appliance.
General Status	Patient is avoiding looking at the ileostomy during care.
Laboratory Data	Potassium 3.6 mEq/L (normal 3.5 to 5 mEq/L) Sodium 137 mEq/L (normal 135 to 145 mEq/L) Creatinine 0.9 mg/dL (normal 0.6 to 1.2 mg/dL)

A nurse is assisting an older adult client who sometimes loses their balance while walking. Which of the following devices is most important for the nurse to use when helping the client ambulate?

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Naxlex Comprehensive Predictor Exams

Correct Answer is B

Explanation

A client with urine retention related to a complete prostatic obstruction requires a urinary catheter to drain the bladder. Which type of catheter is most appropriate for a client that has an obstructed urethra?

Correct Answer is C

Explanation

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