A nurse is helping an older adult client ambulate in the hallway for the first time since admission. The client has brought a standard walker from home. To ensure proper use of the walker and the safety of the client, 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

A. Check that the client lifts the walker and then places it down in front of her.

To ensure proper use of a standard walker and the safety of the client, the nurse should check that the client lifts the walker and then places it down in front of her. This sequence of lifting and moving the walker forward provides stability and support during ambulation.

B. Walk in front of the client to guide her in moving the walker.

The nurse should walk beside or slightly behind the client to provide support and supervision. Walking in front may hinder the client's ability to maneuver the walker.

C. Have the client move one leg forward with the walker.

The proper technique is for the client to move the walker forward and then step into it with the affected leg. Moving one leg forward with the walker may compromise stability.

D. Make sure that the upper bar of the walker is level with the client’s waist.

The correct height of the walker is essential for proper use. The walker should be adjusted to the client's height, with the top bar at the level of the client's wrists when their arms are at their sides, not at the waist.

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Correct Answer is C

Explanation

A. Xerostomia

Xerostomia is dry mouth, a condition where the salivary glands do not produce enough saliva. It can have various causes, including medications, medical conditions, or dehydration. Xerostomia is not directly related to teeth grinding.

B. Halitosis

Halitosis is bad breath. While dental issues, including bruxism (teeth grinding), can contribute to bad breath, halitosis itself does not specifically describe teeth grinding.

C. Bruxism

Bruxism is the medical term for teeth grinding or clenching, especially during sleep. If a client suspects or reports grinding their teeth at night, it is appropriate to document and discuss the issue as bruxism. Bruxism can lead to dental problems, jaw pain, and headaches.

D. Sordes

Sordes refers to a collection of foul matter, such as debris or crusted material, around the mouth. It is not related to teeth grinding.

A. Clean the perineum from front to back. B. Lubricate the catheter. C. Explain to the client that she will feel temporary discomfort. D. Arrange the sterile items on the sterile field.

Correct Answer is D

Explanation

A. Clean the perineum from front to back.

After arranging the sterile items, the next step involves preparing the client for catheter insertion, which includes cleaning the perineum from front to back using appropriate techniques to minimize the risk of infection.

B. Lubricate the catheter.

Following the preparation of the client, the next step involves lubricating the catheter before insertion. Lubrication facilitates the smooth and atraumatic insertion of the catheter.

C. Explain to the client that she will feel temporary discomfort.

Providing information and preparing the client for the procedure is an important aspect, but it typically follows the physical preparation steps. Explaining to the client about potential discomfort should be done before the procedure but after the necessary physical preparations are complete.

D. Arrange the sterile items on the sterile field.

This is the first action to be taken. It involves preparing all the necessary sterile items on a sterile field, ensuring that everything needed for the catheter insertion procedure is organized and ready to maintain aseptic technique.

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A nurse is helping an older adult client ambulate in the hallway for the first time since admission. The client has brought a standard walker from home. To ensure proper use of the walker and the safety of the client, which of the following actions should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client tells the nurse that he suspects that he grinds his teeth at night. Along with giving the client a dental referral, the nurse should explain that the client should see a dentist for this problem, which she should document as which of the following disorders?

Correct Answer is C

Explanation

A nurse is caring for a female client who has a prescription for an indwelling urinary catheter. Which of the following actions should the nurse take first?

Correct Answer is D

Explanation

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