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. Protective prone: The prone position (lying on the stomach) does not allow easy enema administration and is not recommended.

B. Left lateral recumbent: The left lateral position allows gravity to assist with enema administration and helps the fluid move efficiently through the colon.

C. High Fowler's: Sitting upright does not promote proper enema flow, making it ineffective.

D. Dorsal recumbent: Lying on the back does not facilitate enema administration effectively.

A. Output assessment B. General Status C. Stoma assessment D. Laboratory data

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.

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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

A client is on bed rest and an enema has been ordered. In what position should the nurse position the client?

Correct Answer is B

Explanation

Correct Answer is B

Explanation

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