Review the electronic health record. Which action(s) should the nurse take when assisting the client to use a weight-bearing gait with a standard walker? Select all that apply.

Adjust the walker height so the client's arms are fully extended when holding the handles.

Stand slightly behind and on the affected side of the client when they are using a walker.

Have the client lift the device up and forward. Do not allow them to skid it along the floor.

Instruct the client to move the walker forward and then move their affected side forward.

Ensure the client is wearing non-skid footwear before ambulating with the walker.

Answer and Explanation

Correct Answer : B,D,E

A. Adjust the walker height so the client's arms are fully extended when holding the handles: The walker should be adjusted so the elbows are slightly flexed (about 20–30 degrees), not fully extended. Full extension can cause poor posture and increased risk of falls.

B. Stand slightly behind and on the affected side of the client when they are using a walker: Positioning yourself slightly behind and on the weaker or affected side allows the nurse to provide support and assist with balance, reducing fall risk during ambulation.

C. Have the client lift the device up and forward. Do not allow them to skid it along the floor: Standard walkers are designed to slide or “roll” along the floor; clients should not lift the walker. Lifting can cause instability and increase fatigue.

D. Instruct the client to move the walker forward and then move their affected side forward: Proper technique for weight-bearing ambulation with a walker involves moving the walker first, then stepping with the affected limb, followed by the unaffected limb. This ensures support and safety.

E. Ensure the client is wearing non-skid footwear before ambulating with the walker: Non-skid footwear improves traction and decreases the risk of slips and falls, which is essential for safe ambulation postoperatively.

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Correct Answer is B

Explanation

A. Sit the client up in High Fowler's: Elevating the head of the bed can improve lung expansion and oxygenation, but it does not immediately address the critically low respiratory rate and oxygen saturation. This action is supportive but not the highest priority.

B. Call the rapid response team: A respiratory rate of 6 breaths per minute and oxygen saturation of 71% indicate severe hypoxemia and impending respiratory failure. Immediate activation of the rapid response team ensures rapid, coordinated intervention to prevent cardiac or neurologic compromise. Life-threatening instability requires prompt action.

C. Monitor respiratory rate and depth: Ongoing assessment is important, but monitoring alone does not intervene in a life-threatening situation. The client’s condition is critical, and delaying active intervention could result in deterioration. Assessment must be accompanied by emergency response.

D. Prepare for possible intubation: Preparation for intubation is appropriate, but initiating the rapid response team first ensures timely support, equipment, and personnel are available. Immediate coordination is required before advanced procedures.

A. Clean frequently touched surfaces with disinfectant wipes B. Wear gloves during all direct contact with clients C. Wash hands before and after contact with each client D. Clean equipment used for client care with disinfectant wipes

Correct Answer is C

Explanation

A. Clean frequently touched surfaces with disinfectant wipes: Environmental cleaning reduces the microbial load on surfaces, lowering the risk of indirect transmission. While important, it is not as effective as interrupting direct transmission at the source.

B. Wear gloves during all direct contact with clients: Gloves protect against exposure to bodily fluids and pathogens, but they are not a substitute for proper hand hygiene. Microorganisms can still be transmitted if hands are not washed before and after glove use.

C. Wash hands before and after contact with each client: Hand hygiene is the single most effective measure to prevent the spread of microorganisms in healthcare settings. It removes transient pathogens acquired from clients, surfaces, or equipment and significantly reduces healthcare-associated infections.

D. Clean equipment used for client care with disinfectant wipes: Disinfecting shared equipment helps prevent indirect transmission, but it is supplementary to hand hygiene. Equipment cleaning alone does not address pathogens transmitted via direct contact.

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Review the electronic health record. Which action(s) should the nurse take when assisting the client to use a weight-bearing gait with a standard walker? Select all that apply.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse cares for a client with a respiratory rate of 6 breaths per minute and an oxygen saturation of 71% What action should the nurse take first?

Correct Answer is B

Explanation

What is the most important action to prevent the transmission of microorganisms in the hospital setting?

Correct Answer is C

Explanation

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