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 C

Explanation

A: Requesting the risk manager to obtain consent for HIV testing from the client is important but should not be the first action. Immediate steps to reduce the risk of infection are more urgent.

B: Completing an incident report is necessary for documentation and follow-up but is not the immediate priority following a needle stick injury.

C: Washing the site of injury with soap and water is the first and most immediate action. This helps to reduce the risk of infection by removing any potential contaminants from the wound.

D: Consenting to post-exposure treatment with antiretroviral medications is important if there is a risk of HIV exposure. However, this should follow the initial step of cleaning the wound.

A. Clostridium difficile B. Antibiotic therapy C. Formula intolerance D. Bacterial contamination

Correct Answer is C

Explanation

A: Clostridium difficile infection typically develops after prolonged antibiotic use and is not the most likely cause of diarrhea immediately after starting enteral feeding.

B: Antibiotic therapy can cause diarrhea, but it is not the most likely cause in this scenario where the diarrhea started soon after beginning enteral feeding.

C: Formula intolerance is the most likely cause of diarrhea shortly after starting enteral feeding. The patient’s digestive system may not tolerate the formula well, leading to diarrhea.

D: Bacterial contamination is a possible cause but is less likely to cause immediate diarrhea after starting enteral feeding compared to formula intolerance. Proper handling and preparation of the formula should minimize this risk.

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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

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Correct Answer is C

Explanation

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Correct Answer is C

Explanation

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