When instructing a client on the proper use of a cane, which step is essential to ensure stability and safety?

Use the cane on the same side as the injured or weaker leg.

Move the cane and the stronger leg forward together.

Adjust the cane height so the handle is above the waist level.

Hold the cane on the side opposite the injured or weaker leg.

Answer and Explanation

The Correct Answer is D

A. Use the cane on the same side as the injured or weaker leg: This approach is incorrect. The cane should be used on the opposite side of the weaker leg to provide better support and balance during ambulation. Using the cane on the same side would not provide adequate stability and could increase the risk of falling.

B. Move the cane and the stronger leg forward together: This step is not recommended. The proper technique involves moving the cane first, followed by the weaker leg, and then bringing the stronger leg forward. This sequence helps maintain stability and balance while walking.

C. Adjust the cane height so the handle is above the waist level: The cane should be adjusted so that the handle is at the level of the wrist when the client is standing upright, which allows for proper elbow flexion while using the cane. If the handle is too high, it can lead to poor posture and increased strain.

D. Hold the cane on the side opposite the injured or weaker leg: This is the essential step for ensuring stability and safety when using a cane. By holding the cane on the opposite side, the client can use the cane for support while stepping forward with the weaker leg, enhancing balance and reducing the risk of falls. This technique allows for better weight distribution and improved mobility.

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Correct Answer is C

Explanation

A. Wear sterile gloves: Sterile gloves are not necessary for checking a pulse. Sterile gloves are typically used for procedures that involve direct contact with sterile areas or instruments. Checking a pulse does not require maintaining a sterile field, so clean gloves are sufficient.

B. Wear an N95 respirator mask: An N95 respirator mask is typically required for airborne precautions, such as those used for tuberculosis, but not for MRSA. MRSA is primarily transmitted through direct contact with infected wounds or contaminated surfaces, so an N95 mask is not needed for this situation.

C. Wear clean gloves: Wearing clean gloves is the appropriate action when interacting with a client who has MRSA. This helps to prevent the transmission of bacteria and protects both the client and the nurse. Clean gloves should be used for any contact with the client or their environment to minimize the risk of spreading infection.

D. Wear protective eyewear: Protective eyewear is generally used when there is a risk of splashes or sprays of bodily fluids. In this scenario, unless there is a specific risk of such exposure during the pulse check, protective eyewear is not necessary. Clean gloves are the primary requirement for basic contact precautions with MRSA.

A. Vigorously brush the client's teeth. B. Hold the toothbrush at a 90° angle. C. Place two fingers in the client's mouth. D. Turn the client to the side.

Correct Answer is D

Explanation

A. Vigorously brush the client's teeth: Vigorous brushing is not appropriate for an unconscious client. It can cause trauma to the gums or teeth and increase the risk of aspiration if the client has any residual secretions or fluids in the mouth. Gentle brushing should be employed to avoid injury.

B. Hold the toothbrush at a 90° angle: Holding the toothbrush at a 90° angle is not necessary for clients who are unconscious. A more effective angle may be around 45° to effectively clean the surfaces of the teeth while minimizing the risk of gagging or aspiration.

C. Place two fingers in the client's mouth: This action could be harmful, as placing fingers in the mouth of an unconscious client poses a risk of injury or could inadvertently trigger a gag reflex. Instead, proper oral care should be conducted using appropriate tools without placing fingers inside the mouth.

D. Turn the client to the side: Turning the client to the side is the best action as it helps prevent aspiration of secretions or fluids during oral care. This position allows for safer access to the mouth while also promoting drainage of any excess fluids, reducing the risk of choking or aspiration pneumonia.

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When instructing a client on the proper use of a cane, which step is essential to ensure stability and safety?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is C

Explanation

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Correct Answer is D

Explanation

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