a nurse is teaching a client about the correct use of a cane what should the nurse include
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Nursing Elites

ATI RN

ATI Capstone Fundamentals Assessment Proctored

1. When teaching a client about the correct use of a cane, what should the nurse include?

Correct answer: B

Rationale: The correct answer is B. When instructing a client on the use of a cane, it is essential to ensure that the cane has a rubber tip. This rubber tip helps prevent slipping, providing additional stability and safety. Option A, holding the cane on the weaker side, is incorrect as the cane should be held on the stronger side to provide better balance and support. Option C, keeping the cane on the dominant side, is also incorrect because the cane should be held on the stronger side. Option D, using the cane only on stairs, is not comprehensive as the cane can be used for support and balance while walking on level ground as well.

2. A nurse is teaching a client about ways to reduce the risk of deep vein thrombosis (DVT) after surgery. What should the nurse include in the teaching?

Correct answer: B

Rationale: The correct answer is to 'Use sequential compression devices.' Sequential compression devices help prevent DVT by promoting venous return, reducing stasis in the veins, and preventing blood clot formation. Resting in bed for long periods (Choice A) can actually increase the risk of DVT due to decreased mobility. Avoiding leg exercises (Choice C) is also not recommended as mobilization and exercises can help prevent blood clots. Keeping legs crossed (Choice D) can impede blood flow and is not advisable in reducing the risk of DVT.

3. A nurse is caring for a client who has a prescription for a narcotic medication. After administration, what should the nurse do with the unused portion?

Correct answer: C

Rationale: After administering a narcotic medication, any unused portion should be discarded with another nurse as a witness. This procedure ensures proper disposal of controlled substances and prevents misuse or diversion. Storing it for later use (Choice B) is not appropriate due to safety concerns and legal regulations. Returning it to the pharmacy (Choice D) is also not recommended as the medication is already out of the pharmacy's control. Documenting the amount wasted (Choice A) is important for accurate record-keeping but does not address the immediate need for safe disposal of the unused narcotic medication.

4. A healthcare professional is reviewing the medical record of a client with a hip fracture. Which finding is a risk factor for pressure injuries?

Correct answer: C

Rationale: The correct answer is the use of a special mattress. Special mattresses are designed to reduce pressure on bony prominences, thereby helping to prevent pressure injuries. Frequent repositioning (Choice A) is actually a preventive measure for pressure injuries. Poor nutrition (Choice B) can contribute to delayed wound healing but is not a direct risk factor for pressure injuries. Urinary incontinence (Choice D) can increase the risk of skin breakdown but is not a direct risk factor for pressure injuries.

5. A nurse is teaching a client with diabetes mellitus about foot care. What is the most important instruction the nurse should include?

Correct answer: B

Rationale: Inspecting feet daily for injuries is crucial for clients with diabetes to prevent unnoticed wounds from becoming infected. This instruction is the most important as it helps in early detection and management of foot problems. Choice A is incorrect because applying lotion between the toes can lead to excessive moisture, increasing the risk of fungal infections. Choice C is wrong as wearing shoes indoors can also lead to foot issues. Choice D is incorrect because cutting toenails in a rounded shape can result in ingrown toenails, posing a risk for infection.

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