A nurse is contributing to the plan of care for a client who has a chest tube set to continuous suction to relieve a pneumothorax. Which of the following interventions should the nurse include?

Teaching a client to use a cane focuses on improving balance, stability, and safety during ambulation, especially when unilateral weakness is present. A cane should be used on the stronger side of the body to provide optimal support for the weaker lower extremity. Proper sequencing of cane and leg movement helps redistribute weight and reduce fall risk. Correct technique is essential for clients recovering from neurologic conditions such as stroke.

Rationale:
A. Positioning the cane 30.5 cm (12 in) to the side of the body is incorrect because the cane should be held close to the body for stability. Holding it too far away increases the risk of imbalance and reduces effective weight-bearing support. Proper placement is directly adjacent to the stronger leg.

B. Placing the cane on the right side is correct because the cane should be used on the unaffected or stronger side when the client has left-sided weakness. This allows the right side to support body weight while the left, weaker side advances safely. This technique improves balance and reduces fall risk in clients with conditions such as Stroke.

C. Advancing the cane 40.64 cm (16 in) with each step is incorrect because the cane should be moved only a short distance forward, typically about 15–25 cm (6–10 in). Moving it too far ahead reduces stability and increases the risk of loss of balance. Controlled, small movements are essential for safe ambulation.

D. Moving the right foot forward first is incorrect because the sequence should involve moving the cane and the weaker (left) leg first, followed by the stronger leg. Advancing the strong leg first disrupts balance and does not provide proper support for the affected side. Correct sequencing ensures safety and coordination during walking.

Dehydration results from excessive fluid loss or inadequate fluid intake, leading to decreased intravascular volume and impaired tissue perfusion. Clinical manifestations reflect reduced circulating volume and compensatory cardiovascular responses aimed at maintaining blood pressure. A key feature of hypovolemia is orthostatic or postural changes in blood pressure due to inadequate vascular filling when the client changes position. Early recognition of these signs is essential to prevent progression to hypovolemic shock.

Rationale:
A. Peripheral edema is not expected in dehydration because it reflects fluid excess in the interstitial spaces rather than fluid deficit. Edema is commonly associated with conditions such as heart failure, renal impairment, or hypoalbuminemia. In dehydration, fluid volume is reduced, so tissue swelling does not occur.

B. Bradycardia is not typical in dehydration; instead, tachycardia is expected as a compensatory mechanism to maintain cardiac output. The heart rate increases to help preserve perfusion in response to reduced circulating volume. A slow heart rate would be inconsistent with hypovolemic states.

C. Postural hypotension is expected because reduced intravascular volume limits the body’s ability to maintain blood pressure when changing position. When a client stands, gravity causes blood pooling in the lower extremities, and inadequate volume results in a drop in cerebral perfusion. This leads to dizziness, lightheadedness, and potential syncope, making it a hallmark sign of dehydration.

D. Distended neck veins are associated with fluid overload states such as heart failure or fluid retention, not dehydration. In hypovolemia, jugular venous pressure is typically low or flat due to reduced circulating blood volume. Therefore, this finding is inconsistent with dehydration.