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

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

Remove the rubber tip when using the cane.

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

Place the cane approximately 61 cm (24 in) in front of her feet before advancing

Answer and Explanation

The Correct Answer is A

A: The correct instruction is to hold the cane on the right side, which is the side opposite the weaker leg. This provides better support and balance for the weaker side.

B: Removing the rubber tip from the cane is not recommended. The rubber tip provides traction and stability, reducing the risk of slipping.

C: Advancing the right leg and the cane together is incorrect. The cane should move with the weaker leg (left leg in this case) to provide support during ambulation.

D: Placing the cane 61 cm (24 in) in front of the feet is too far. The cane should be placed about 15-25 cm (6-10 in) in front of the feet to provide optimal support and balance.

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Correct Answer is B

Explanation

A: Drinking cranberry juice each day can help prevent UTIs. Cranberry juice contains compounds that may prevent bacteria from adhering to the urinary tract walls, reducing the risk of infection.

B: Wiping the perineal area from back to front after urination is incorrect and increases the risk of introducing bacteria from the anal area to the urethra, leading to UTIs. The correct method is to wipe from front to back to minimize this risk.

C: Emptying the bladder regularly and completely is an important measure to prevent UTIs. It helps flush out bacteria from the urinary tract and reduces the risk of infection.

D: Drinking 8 cups of liquid each day is recommended to maintain adequate hydration and promote regular urination, which helps prevent UTIs by flushing out bacteria.

A. The client is attempting to remove the restraint. B. The client’s hand is cold and pale. C. The client has full range of motion in her wrist. D. The client has a capillary refill of less than 2 seconds.

Correct Answer is B

Explanation

A: The client attempting to remove the restraint does not necessarily indicate a need to loosen it. The nurse should assess the reason for the client’s behavior.

B: The client’s hand being cold and pale indicates compromised circulation, which requires immediate loosening of the restraint to restore blood flow.

C: Full range of motion in the wrist suggests that the restraint is not too tight and does not need to be loosened.

D: A capillary refill of less than 2 seconds indicates good circulation, so the restraint does not need to be loosened.

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

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is providing teaching to a client about measures to prevent urinary tract infections (UTIs). Which client statement indicates a need for further teaching?

Correct Answer is B

Explanation

A nurse is assessing a client who has a wrist restraint applied. For which of the following findings should the nurse loosen the restraint?

Correct Answer is B

Explanation

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