A nurse is monitoring a client who ambulates with a cane. Which of the following actions by the client should the nurse expect?

The client holds the cane on the stronger side of their body.

The client advances the cane forward 12.7 cm (5 in).

The client moves their stronger leg forward first.

The top of the cane is at the same height as the client's waist.

Answer and Explanation

The Correct Answer is A

A. The client holds the cane on the stronger side of their body: Holding the cane on the stronger side improves balance and support while reducing strain on the weaker limb. It also helps coordinate movement and distribute weight more efficiently during ambulation.

B. The client advances the cane forward 12.7 cm (5 in): The cane should typically be advanced 15 to 25 cm (6 to 10 inches) forward for optimal support. Advancing it only 5 inches may provide insufficient balance assistance during walking.

C. The client moves their stronger leg forward first: The weaker leg should move forward after the cane to allow the stronger leg to support most of the weight. This pattern maximizes stability and safety during ambulation.

D. The top of the cane is at the same height as the client's waist: The cane should be level with the wrist crease when the client’s arms are relaxed at their sides, not at waist level. A cane that is too high or low can cause discomfort or improper posture.

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Correct Answer is A

Explanation

A. Interlock their fingers and hold their hands away from their body above their waist: This position maintains the sterility of the gloves by keeping the hands visible and above waist level, which is the accepted sterile field boundary.

B. Keep their arms at the sides of their body with their hands in a relaxed position: Keeping hands close to the body or at the sides risks contamination because the hands might touch nonsterile surfaces or the body, which is outside the sterile field.

C. Place one hand over the other against the part of the gown covering their upper body: Touching the gown, which is considered sterile only in the front above the waist, can risk contamination if hands move unexpectedly or if the gown surface is touched by nonsterile areas.

D. Clasp their hands together in a relaxed position behind their body at their waist: Positioning hands behind the back limits visibility and control over the sterile field, increasing the risk of contamination by touching nonsterile surfaces or moving out of the sterile boundary.

A. Prick the side of the client's finger. B. Squeeze the client's finger until a blood drop forms. C. Elevate the client's hand above the level of the heart. D. Apply clean gloves. E. Cleanse the client's finger with an iodine swab.

Correct Answer is ["A","D"]

Explanation

A. Prick the side of the client's finger: Pricking the side (lateral aspect) of the fingertip reduces discomfort and provides good blood flow compared to the center of the finger, making it the preferred site for capillary blood sampling.

B. Squeeze the client’s finger until a blood drop forms: Squeezing or "milking" the finger vigorously after the prick can cause hemolysis (rupture of red blood cells) and dilute the specimen with interstitial fluid. This can lead to inaccurate results.

C. Elevate the client’s hand above the level of the heart: Elevating the hand above heart level can reduce blood flow to the finger, making it harder to obtain an adequate sample. The hand should be positioned at or slightly below heart level.

D. Apply clean gloves: Wearing clean gloves protects both the client and nurse from exposure to bloodborne pathogens and maintains infection control standards.

E. Cleanse the client’s finger with an iodine swab: Iodine is not typically used for capillary puncture site cleansing due to potential skin irritation and interference with some tests. An alcohol swab is preferred for cleaning before puncture.

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A nurse is monitoring a client who ambulates with a cane. Which of the following actions by the client should the nurse expect?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is A

Explanation

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Correct Answer is ["A","D"]

Explanation

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