A nurse is planning care for a client who is prescribed a cane for ambulation. Which of the following nursing actions should the nurse include in the plan of care?

Remind the client to place the cane on the unaffected side.

Adjust the length of the cane to equal the distance from the client's iliac crest to the floor.

Remove the rubber tip from the cane to enhance ambulation.

Place the cane safely in the closet during naps and at bedtime.

Answer and Explanation

The Correct Answer is A

A. Placing the cane on the unaffected side helps to provide better support and balance for the client. It allows the client to shift weight away from the affected side, reducing strain and risk of falls.

B. The cane should be adjusted to the height of the wrist crease when the client stands with arms relaxed at their sides, not the iliac crest. This ensures proper posture and effective use of the cane.

C. Removing the rubber tip from the cane is unsafe as the rubber tip provides traction and prevents slipping. Without it, the cane could easily slide on smooth surfaces, increasing the risk of falls.

D. Placing the cane in the closet during naps and bedtime is not practical. The client may need to use the cane immediately upon waking, and it should be easily accessible to prevent accidents.

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Correct Answer is B

Explanation

A. 3hr oral glucose tolerance test - This test is typically used for diagnosing gestational diabetes or impaired glucose tolerance, not for long-term management.

B. HbA1c - Hemoglobin A1c reflects the average blood glucose levels over the past 2-3 months and is a reliable indicator of long-term glycemic control.

C. Fasting blood glucose test - This provides a snapshot of blood glucose levels at a specific point in time and is not as reliable for assessing long-term glycemic control as HbA1c.

D. Urinalysis for ketones - Urinalysis for ketones is useful for detecting acute complications such as diabetic ketoacidosis but does not reflect long-term management of blood glucose levels.

A. "Your PICC line will allow long-term access for antibiotic therapy." B. "You should use a 5-milliliter barrel syringe to flush your PICC line at home." C. "Your PICC line must be placed in your nondominant arm." D. "You should immobilize the arm with the PICC line using a sling."

Correct Answer is A

Explanation

A. "Your PICC line will allow long-term access for antibiotic therapy." - PICC lines are often used for long-term administration of medications, including antibiotics, due to their durability and ease of use.

B. "You should use a 5-milliliter barrel syringe to flush your PICC line at home." - The size of the syringe used to flush a PICC line depends on the facility's protocol and the client's specific

needs. Specific instructions regarding syringe size should be provided by the healthcare provider or nurse.

C. "Your PICC line must be placed in your nondominant arm." - The choice of arm for PICC line placement depends on various factors, including vein integrity and the client's comfort. There is no strict requirement for the PICC line to be placed in the nondominant arm.

D. "You should immobilize the arm with the PICC line using a sling." - Immobilizing the arm with a sling is not typically necessary after PICC line placement. Clients are usually instructed to avoid excessive movement and to keep the arm clean and dry to prevent complications.

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A nurse is planning care for a client who is prescribed a cane for ambulation. Which of the following nursing actions should the nurse include in the plan of care?

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Naxlex Comprehensive Predictor Exams

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