The nurse is helping a client to climb stairs while using a cane. Which step will the nurse emphasize?
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Course
NUR 311
Institution
NUR 311
The nurse is helping a client to climb stairs while using a cane. Which step will the nurse emphasize?
Advance the weaker leg up the stair first, followed by the cane and stronger leg.
Place the cane one step above and use the stronger leg to pull the weaker leg upward.
Advance the stronger leg ...
NUR 311L Midterm Exam Questions and
Correct Answers
TEACHING HOW TO USE CANE ✅-->
The nurse is helping a client to climb stairs while using a cane. Which step will the nurse
emphasize?
Advance the weaker leg up the stair first, followed by the cane and stronger leg.
Place the cane one step above and use the stronger leg to pull the weaker leg upward.
Advance the stronger leg up the stair first, followed by the cane and weaker leg.
Place the cane one step above and use the weaker leg to pull the stronger leg upward.
✅Advance the stronger leg up the stair first, followed by the cane and weaker leg.
The client has decreased strength in the left leg. How will the nurse instruct the client to
hold a cane for assistance?
on the left side
on the right side
toward the front
toward the back ✅on the right side
What will the nurse teach the client who is ambulating with a cane to do after advancing
the cane a short distance?
While supporting weight on the stronger leg and the cane, advance the weaker foot
forward, parallel with the cane.
While supporting weight on the weaker leg and the cane, advance the stronger foot
forward, parallel with the cane.
While supporting weight on the stronger leg and the cane, advance the stronger foot
forward, parallel with the cane.
While supporting weight on the weaker leg and the cane, advance the weaker foot
forward, parallel with the cane. ✅While supporting weight on the stronger leg and the
cane, advance the weaker foot forward, parallel with the cane.
,The nurse is teaching proper cane use to a client who has had ankle surgery. The client
has been cleared to begin bearing weight on the affected leg. What projected outcome
will the nurse question? ✅Reported increased strength in the weaker leg.
A client who is recovering from surgery is beginning to ambulate. This client is strong
enough to walk without assistance but has poor balance. Which type of mobility aid is
most appropriate for this client? ✅cane with four prongs on the end (quad cane)
FALL PREVENTION ✅-->
A nurse is counseling an older adult client on fall prevention in the home before the
client is discharged from the hospital. Which action does the nurse recommend to the
client? ✅Consult with your health care provider about beginning an exercise program.'
A nurse is caring for a client at risk for falls who does not have access to an activated
bed or chair alarm. How often should the nurse assess this client? ✅every 60 minutes
Which recommendation(s) will the nurse include in a teaching plan for preventing falls in
the home? Select all that apply. ✅Avoid climbing on a chair or table to reach items that
are too high to reach.
Use a night light.
Remove clutter from walkways.
Keep electrical and telephone cords against the wall and out of walkways.
The nurse cares for a client who is postoperative after an abdominal surgery. Which is
the most important statement for the nurse to use in teaching this client? ✅Use the call
bell for any needs and wear nonslip footwear.
The nurse has finished a discussion with an older adult client about dangers in the
home. The nurse recognizes that the instruction was effective when the client identifies
which common risk(s) in the home? Select all that apply. ✅clutter, polypharmacy,
extension cords
What are the 5 P's ✅Pain
Possessions
Potty
Position
Pathway
ORAL CARE ✅-->
,The nurse is providing oral care for a client who has suffered head trauma. The client is
unresponsive. How will the nurse best position the client?
Side-lying
Prone
Supine
Semi-Fowler ✅Side-lying
The nurse is providing oral care to an unconscious client. Which piece of equipment is
important to use to individualize care for this client?
The unresponsive client's spouse at bedside asks the nurse about oral care. The
spouse states, 'If my spouse is not eating, why do you still brush the teeth?' How does
the nurse best respond?
'Mouth care during this time helps prevent complications.'
'Without swallowing, bacteria get trapped in the mouth.'
'Dental care is still important, even when not chewing.'
'It is comforting to have moist oral mucosa during this time.' ✅'Mouth care during this
time helps prevent complications.'
A nurse provides oral care for an older adult client who cannot effectively manipulate a
toothbrush. How often will the nurse brush and floss the client's teeth?
Twice a day
Once a day
Three times a day
Four times a day ✅Twice a day
When providing oral care to an unconscious client, which action will the nurse take?
Place the head of the client's bed in high-Fowler position.
Ensure there is a towel and basin positioned for drainage.
Brush the tongue and each tooth surface multiple times.
Have endotracheal suction supplies at the bedside. ✅Ensure there is a towel and
basin positioned for drainage.
The acute care nurse is talking with a client who just finished performing oral care. The
client states, 'I have some whitish-yellow patches on my tongue. Should I be
concerned?' How will the nurse respond?
, 'Let me assess the patches. They may indicate the development of a fungal infection.'
'The patches are probably the result of ineffective brushing. I will get you a new
toothbrush.'
'Is this the first time you noticed them? These types of patches are a normal finding in
most adults.'
'What type of milk did you drink during your last meal? These patches often occur after
drinking whole milk.' ✅'Let me assess the patches. They may indicate the development
of a fungal infection.'
The nurse is providing oral care to a hospitalized client. Which outcome of this
intervention is the priority?
Decreasing the incidence of hospital-acquired pneumonia
Promoting the client's sense of well-being
Preventing dental caries
Preventing deterioration of the oral cavity ✅Decreasing the incidence of hospital-
acquired pneumonia
A client is bedbound. After assisting the client with oral care, what action does the nurse
take?
Dispose of the used toothbrush, basin, and cups.
Assist the client to a comfortable position in the bed.
Place the supplies on the edge of the overbed table.
Inspect the oral cavity for dryness, erythema, or bleeding. ✅Assist the client to a
comfortable position in the bed.
The nurse is assisting a hospitalized client with oral care. How will the nurse position the
client?
sitting upright at the edge of the bed
with head of the bed at 10 degrees
with head of the bed at 30 degrees
with head of the bed at 45 degrees ✅sitting upright at the edge of the bed
A client has requested assistance with tooth brushing. What necessary supply(ies) will
the nurse gather? Select all that apply.
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