A nurse is teaching an older adult client who has left-sided weakness about cane use. Which of the following instructions should the nurse include?

When walking, move your left foot forward first.

Keep your elbow straight when you hold the cane.

Move the cane forward 18 inches with each step.

Hold the cane with your left hand.

Answer and Explanation

The Correct Answer is A

A reason:

When walking, moving the left foot forward first is correct. For clients with left-sided weakness, the cane should be used to provide support for the weak side. Moving the left foot first while using the cane helps maintain balance and stability.

B reason:

Keeping the elbow straight when holding the cane is incorrect. The elbow should be slightly bent when holding the cane to allow for better control and shock absorption, reducing strain on the arm.

C reason:

Moving the cane forward 18 inches with each step is incorrect. The cane should be moved a comfortable distance forward, typically about 6 to 12 inches, to maintain stability and support without overreaching.

D reason:

Holding the cane with the left hand is incorrect. For left-sided weakness, the cane should be held in the right hand to provide support and balance on the opposite side of the weakness.

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Correct Answer is A

Explanation

A reason:

Wearing a mask is essential for droplet precautions to prevent the nurse from inhaling respiratory droplets that could contain infectious agents. Droplet precautions are necessary for infections that are spread through large respiratory droplets, such as influenza and pertussis.

B reason:

While gloves are important for contact precautions, they are not specifically required for setting up a meal tray under droplet precautions. The primary focus should be on preventing the inhalation of infectious droplets.

C reason:

Goggles are not typically necessary for droplet precautions unless there is a risk of splashes or sprays. The primary protective equipment is a mask.

D reason:

A gown is used for contact precautions to protect clothing from contamination. It is not required for droplet precautions unless there is a risk of direct contact with infectious materials.

A. Dissolve the medication in water and give it through the NG tube. B. Request a prescription for an oral formulation of the medication. C. Administer the medication under the client's tongue. D. Administer the crushed medication through the NG tube.

Correct Answer is C

Explanation

A reason:

Dissolving the medication in water and giving it through the NG tube is incorrect. Sublingual medications are designed for rapid absorption under the tongue and should not be altered.

B reason:

Requesting a prescription for an oral formulation of the medication is unnecessary if the client can take the sublingual form.

C reason:

Administering the medication under the client's tongue is correct. This route allows for the proper absorption and effectiveness of the sublingual medication.

D reason:

Administering the crushed medication through the NG tube is incorrect. Crushing sublingual medications can alter their effectiveness and absorption.

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A nurse is teaching an older adult client who has left-sided weakness about cane use. Which of the following instructions should the nurse include?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is C

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