The nurse is educating a patient about the use of a cane due to weakness of the left leg.
Which statement by the patient would indicate teaching has been effective?
"I know the cane helps narrow my base of support and improve my balance.”.
"I will assure the tip of the cane is at least 12 inches to the side of the foot.”.
"I am going to adjust the cane so my wrist is lower than the top of the cane.”.
"I will ambulate by advancing first my cane then my weak leg and lastly my strong leg.”.
The Correct Answer is A
Choice A rationale:
This statement indicates effective teaching. Narrowing the base of support and improving balance are key aspects of using a cane properly. A patient who understands this concept demonstrates comprehension of the teaching.
Choice B rationale:
Placing the tip of the cane at least 12 inches to the side of the foot is incorrect. The cane should be placed about 6 inches to the side of the foot for proper support and balance.
Choice C rationale:
Adjusting the cane so the wrist is lower than the top of the cane is incorrect. The top of the cane should be at the level of the wrist for optimal use.
Choice D rationale:
Advancing the cane first, followed by the weak leg and then the strong leg, is incorrect. The correct sequence is advancing the cane and the weak leg simultaneously and then followed by the strong leg to maintain balance and support.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale:
The nurse mistakenly calling the patient's daughter "your wife" is a communication error but does not qualify as a sentinel event. Sentinel events are serious, largely preventable patient safety incidents that result in significant harm or death to the patient. Miscommunication, while important to address, does not fall under the category of a sentinel event.
Choice B rationale:
A surgical procedure performed on the wrong leg of a patient is a classic example of a sentinel event. Wrong-site surgery is a serious medical error that can lead to severe consequences for the patient. Proper protocols and procedures, such as time-outs and site marking, are in place to prevent such incidents, making this a sentinel event that requires immediate investigation and analysis to prevent recurrence.
Choice C rationale:
The surgical procedure being postponed by 30 minutes, while potentially inconvenient, does not constitute a sentinel event. Delays in surgical schedules are not uncommon due to various reasons such as emergencies or the complexity of preceding procedures. While delays should be minimized, they do not necessarily result in patient harm or death, making them different from sentinel events.
Choice D rationale:
The nurse failing to raise the bed to a working height during patient care is a safety concern but does not qualify as a sentinel event. It is important for nurses to adhere to proper body mechanics and safety protocols to prevent accidents and injuries. While this situation requires correction and education, it does not meet the criteria of a sentinel event.
Correct Answer is C
Explanation
Choice A rationale:
During inhalation, carbon dioxide levels are lower in the alveoli due to the exchange of gases. The higher concentration of carbon dioxide is found in the blood, which diffuses into the alveoli for elimination during exhalation.
Choice B rationale:
Alveoli do not collapse during the inhalation cycle. Surfactant, a substance produced by type II alveolar cells, reduces surface tension and prevents alveoli from collapsing, ensuring efficient gas exchange.
Choice C rationale:
Oxygen moves from the alveoli to the capillaries, while carbon dioxide moves from the capillaries to the alveoli. This exchange of gases occurs due to differences in partial pressures, facilitating the uptake of oxygen by red blood cells and the removal of carbon dioxide from the body.
Choice D rationale:
Exhaling carbon dioxide is a passive process that does not require significant effort. The respiratory muscles relax during exhalation, allowing the lungs to passively expel carbon dioxide from the body as a waste product of metabolism.
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