The practical nurse (PN) is assigned to care for an older male client who is recovering from a stroke. When assisting this client to ambulate with the use of a cane, where should the PN place the cane in relation to the client's body?

On the same side as the affected extremity.

Approximately one foot away from the body to stabilize balance.

On the opposite side of the affected extremity.

In front of the body to lean on while stepping forward.

Answer and Explanation

The Correct Answer is C

A. On the same side as the affected extremity: Placing the cane on the affected side reduces stability because the weaker side does not provide sufficient support. This increases the risk of falls and improper gait.

B. Approximately one foot away from the body to stabilize balance: Holding the cane too far from the body can compromise balance and coordination. Proper cane placement should maintain stability close to the body while allowing natural movement.

C. On the opposite side of the affected extremity: The cane should be held on the side opposite the weaker or affected limb. This provides optimal support and balance during ambulation, allowing the client to bear weight safely while stepping forward with the affected leg.

D. In front of the body to lean on while stepping forward: Leaning on the cane excessively shifts weight forward and can destabilize the client. The cane is intended to provide lateral support rather than function as a crutch for leaning.

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Correct Answer is A

Explanation

A. An older adult with Alzheimer's who often wanders out of the room: The UAP can safely monitor and assist this client with ambulation, ensuring safety and preventing falls. Tasks like observation and redirecting the client are within the UAP’s scope of practice under supervision.

B. An adult postoperative client who is ready for discharge instructions: Discharge teaching involves providing education, assessing understanding, and reinforcing care plans, which are nursing responsibilities and cannot be delegated to a UAP.

C. An adolescent recently admitted with a suspected ruptured appendix: This client requires ongoing assessment, monitoring for signs of acute deterioration, and communication of findings to the RN, which are beyond the UAP’s scope.

D. An adult who is receiving blood and requires every 30 minute vital signs: Blood transfusion monitoring is a high-risk intervention requiring assessment skills, recognition of adverse reactions, and immediate nursing intervention, so it cannot be delegated to the UAP.

A. Checks the medical record for the correct signed consent form prior to the examination. B. Asks if the client understands the exam and why the consent form must be signed. C. Explains the examination and ask the client to sign the consent form. D. Explains to a family member and obtain their signature on the consent form.

Correct Answer is A

Explanation

A. Checks the medical record for the correct signed consent form prior to the examination: The PN’s role is to verify that a valid, signed consent form is on file before the procedure. This ensures legal and ethical compliance while confirming that the client has been properly informed by the provider.

B. Asks if the client understands the exam and why the consent form must be signed: Assessing client understanding is the responsibility of the provider who explains the procedure. The PN can reinforce understanding but cannot obtain informed consent independently.

C. Explains the examination and asks the client to sign the consent form: Explaining the procedure and obtaining signatures is the provider’s responsibility. The PN can clarify information and answer questions, but cannot replace the provider in securing consent.

D. Explains to a family member and obtain their signature on the consent form: Consent must come from the client unless they are legally unable to provide it. Involving a family member without proper authorization could violate the client’s rights and legal requirements.

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The practical nurse (PN) is assigned to care for an older male client who is recovering from a stroke. When assisting this client to ambulate with the use of a cane, where should the PN place the cane in relation to the client's body?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The practical nurse (PN) is working with the registered nurse (RN) and unlicensed assistive personnel (UAP) to care for four clients on a medical-surgical unit. Which client's care can the PN assign to the UAP?

Correct Answer is A

Explanation

Prior to an invasive examination of a hospitalized client, a consent form should be obtained. Which action best describes the responsibility of the practical nurse (PN)?

Correct Answer is A

Explanation

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