A nurse is providing discharge teaching to a client who will be using a cane to maintain mobility at home following a left knee arthroplasty. Which of the following statements by the client indicates an understanding of the safe use of a cane?

"I'll use the cane to support my body weight.".

"I will put the cane next to my right leg when I walk.".

"My partner is bringing in a wooden cane we have at home.".

"I will move my right leg forward first.".

Answer and Explanation

The Correct Answer is B

Choice A rationale:

Using the cane to support body weight is not the correct technique. The purpose of a cane is to provide balance and support, not to bear the entire body weight. Placing the entire body weight on the cane can lead to instability and falls.

Choice B rationale:

Placing the cane next to the unaffected leg (right leg in this case) is the correct technique. This positioning provides additional support and stability on the side opposite to the affected leg. This helps in maintaining balance and reducing the risk of falling.

Choice C rationale:

The type of cane is not as relevant as using it correctly. The material of the cane doesn't impact the client's understanding of how to use it safely. While using a wooden cane might be acceptable, the material itself is not an indication of the client's understanding of safe cane use.

Choice D rationale:

Moving the right leg forward first is not the correct technique for using a cane. The correct foot to move forward first is the affected leg, in this case, the left leg. This allows the client to maintain a stable base of support while moving.

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Correct Answer is C

Explanation

Choice A rationale:

Request additional information about the caller's relationship to the client. Rationale: While understanding the caller's relationship to the client is important for confirming the legitimacy of the request, it doesn't address the core concern of maintaining client confidentiality. Sharing information with individuals solely based on their relationship can still lead to breaches in privacy.

Choice B rationale:

Provide a general update about the client's condition over the telephone. Rationale: Providing a general update over the telephone is not a secure method of maintaining client confidentiality. General updates can inadvertently disclose sensitive information and should only be communicated through secure and private channels.

Choice C rationale:

Refer the family member to the client's provider for the update. Rationale: This choice is the correct answer as it ensures that the family member receives accurate and appropriate information from the authorized source, which is the client's healthcare provider. This approach maintains the confidentiality of the client's medical information and adheres to privacy regulations.

Choice D rationale:

Encourage the family member to contact the client directly for information. Rationale: Encouraging direct contact between the family member and the client for information sharing can potentially compromise the client's privacy. The client might not want their condition disclosed to certain individuals, and it's the responsibility of the healthcare provider to ensure that sensitive information is shared appropriately and securely.

A. Position the client so that they are lying flat. B. Increase the client's oral fluid intake. C. Prepare the client for emergency surgery. D. Apply gentle pressure to the dressed wound.

Correct Answer is C

Explanation

Choice A rationale:

Positioning the client so that they are lying flat (Choice A) is not the appropriate action after evisceration. Evisceration is the protrusion of internal organs through a wound, and lying flat could potentially put pressure on the exposed organs and worsen the situation.

Choice B rationale:

Increasing the client's oral fluid intake (Choice B) is generally a good practice for postoperative care, but it is not the priority in the case of evisceration. The primary concern is protecting the exposed organs and preventing infection.

Choice C rationale:

Preparing the client for emergency surgery (Choice C) is the correct action after observing evisceration. Evisceration is a surgical emergency, and the client needs immediate medical intervention to repair the wound and secure the exposed organs.

Choice D rationale:

Applying gentle pressure to the dressed wound (Choice D) is contraindicated in the case of evisceration. Applying pressure could further damage the exposed organs and increase the risk of infection.

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A nurse is providing discharge teaching to a client who will be using a cane to maintain mobility at home following a left knee arthroplasty. Which of the following statements by the client indicates an understanding of the safe use of a cane?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse receives a telephone call from a client's family member, who asks the nurse for an update on the client's condition. Which of the following actions should the nurse take to maintain the client's confidentiality?

Correct Answer is C

Explanation

A nurse is caring for a postoperative client and observes evisceration of the abdominal surgical wound. After covering the wound with a sterile, saline-soaked dressing, which of the following actions should the nurse take?

Correct Answer is C

Explanation

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A nurse is providing teaching to a client who has a new colostomy. Which of the following actions should the nurse take when demonstrating how to change the ostomy appliance?

A nurse is planning teaching for a client who has a new diagnosis of type 2 diabetes mellitus. Which of the following actions should the nurse take prior to performing the teaching?

A nurse is planning care for a client who has a fever due to an infection. Which of the following interventions should the nurse include in the plan of care?

A nurse is auscultating a client's carotid artery while performing a focused cardiac assessment and hears a bruit. The nurse should identify this finding as a manifestation of which of the following conditions?

A nurse is preparing to notify the provider about a change in a client's status. Which of the following information should the nurse plan to include in the "background" portion of the Situation, Background, Assessment, Recommendation (SBAR) Communication tool?