a nurse is providing teaching to a client who is learning to use a cane due to left leg weakness which instruction is correct
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Nursing Elites

ATI LPN

ATI NCLEX PN Predictor Test

1. A client is learning to use a cane due to left-leg weakness. Which instruction is correct?

Correct answer: B

Rationale: The correct instruction when using a cane due to leg weakness is to maintain two points of support on the floor at all times. This provides stability and support while walking. Choice A is incorrect because the cane should be used on the weaker side to provide assistance. Choice C is incorrect as the cane and weak leg should move together for support. Choice D is incorrect as advancing the cane too far with each step may compromise balance and stability.

2. What is the nurse's role in preoperative patient care?

Correct answer: A

Rationale: The nurse plays a crucial role in preoperative patient care by providing education and ensuring NPO (nothing by mouth) status. This helps prepare the patient for surgery by ensuring they understand the procedure, what to expect, and also by following necessary preoperative fasting guidelines. While obtaining the patient's health history (choice C) is important for overall patient assessment, it is typically done during the preoperative assessment but does not specifically pertain to the nurse's role. Ensuring informed consent (choice B) is primarily the responsibility of the healthcare provider performing the procedure. Confirming the patient's surgical site (choice D) is usually the responsibility of the surgical team and is done immediately before the surgery to prevent errors.

3. A client is prescribed simvastatin. Which instruction should the nurse provide during teaching?

Correct answer: B

Rationale: The correct answer is B: 'Avoid drinking grapefruit juice.' Grapefruit juice can increase the risk of toxicity when taken with simvastatin. Instructing the client to avoid grapefruit juice helps prevent this interaction. Choice A is incorrect because the timing of medication administration for simvastatin is usually in the evening. Choice C is unrelated to simvastatin therapy. Choice D is not necessary for monitoring while taking simvastatin.

4. A client is being cared for by a nurse with dehydration. What is the priority intervention?

Correct answer: C

Rationale: The correct answer is to monitor the client's fluid and electrolyte levels. When caring for a client with dehydration, it is crucial to assess and monitor their fluid and electrolyte status to guide appropriate interventions. Administering antiemetics may help with nausea but does not address the underlying issue of dehydration. Encouraging the client to drink oral rehydration solutions is beneficial but may not be the immediate priority if the client is severely dehydrated. Administering intravenous fluids may be necessary based on the assessment of fluid and electrolyte levels, making monitoring these levels the priority intervention.

5. What is the proper technique for administering an intramuscular (IM) injection?

Correct answer: A

Rationale: The correct technique for administering an intramuscular (IM) injection is to locate the injection site and insert the needle at a 90-degree angle. This angle ensures that the medication is delivered into the muscle for proper absorption. Choice B is incorrect because a 45-degree angle is typically used for subcutaneous injections, not intramuscular. Choice C is incorrect as massaging the site after an injection can cause the medication to disperse unevenly. Choice D is incorrect as a 15-degree angle would not reach the muscle layer effectively for an IM injection.

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