A nurse is reinforcing teaching with a client who has left hemiparesis about how to use a cane. Which of the following instructions should the nurse include?

Place the cane about 61 cm (24 in) in front of the feet before advancing.

Remove the rubber tip when using the cane.

Hold the cane on the right side to provide support for the weaker leg.

Advance the right leg and the cane together to support the weaker leg

Answer and Explanation

The Correct Answer is C

A. The cane should be placed about 15–25 cm (6–10 in) in front of the feet, not 61 cm (24 in), which is too far and unsafe.
B. The rubber tip should never be removed; it provides traction and prevents slipping.
C. The cane is held on the stronger (right) side to provide support and balance for the weaker (left) leg—this is correct teaching.
D. The cane should advance at the same time as the weaker (left) leg, not the stronger (right) leg.

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Correct Answer is B

Explanation

A. A registered dietitian focuses on nutritional needs and meal planning, not physical feeding assistance.
B. An occupational therapist specializes in helping clients maintain independence in daily activities, including using adaptive devices for feeding, making this the correct referral.
C. A speech pathologist addresses swallowing and communication difficulties, not physical feeding mechanics.
D. A social worker assists with psychosocial needs, resources, and support services, not adaptive feeding techniques.

A. Loosen the knots on the ropes if the client is experiencing pain. B. Check the client's bony prominences every 12 hr. C. Cleanse the client's pin sites with povidone-iodine. D. Ensure the client's weights are hanging freely from the bed.

Correct Answer is D

Explanation

A. The nurse should never loosen knots or adjust the traction without a provider’s prescription, as this can compromise alignment and healing.
B. Bony prominences should be checked at least every 8 hr (not every 12 hr) to prevent skin breakdown and pressure injuries.
C. Povidone-iodine is no longer recommended for pin site care because it can damage tissue; chlorhexidine or sterile saline is typically used per protocol.
D. Ensuring the weights hang freely maintains the continuous pulling force necessary for proper alignment and healing of the fracture, making this the correct action.

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A nurse is reinforcing teaching with a client who has left hemiparesis about how to use a cane. Which of the following instructions should the nurse include?

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Correct Answer is B

Explanation

A nurse is assisting with the care of a client who has a femur fracture and is in skeletal traction. Which of the following actions should the nurse take?

Correct Answer is D

Explanation

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