Nurse Evangeline teaches an elderly client how to use a standard aluminum walker. Which of the following behaviors, if demonstrated by the client, indicates that the nurse's teaching was effective?

Correct Answer: A

Rationale: The correct answer is A because it demonstrates the proper technique for using a standard aluminum walker. By pushing the walker forward 12 inches first and then taking small steps while leaning on the walker, the client ensures stability and support. This method helps prevent falls and promotes safe mobility. Option B is incorrect because lifting the walker may lead to instability and increase the risk of falling. Option C is incorrect because supporting weight on the walker while advancing may not provide adequate support. Option D is incorrect because sliding the walker forward may cause the client to lose balance and stability.

Correct Answer: C

Rationale: The correct answer is C, hyperkalemia. In acute renal failure, the kidneys are unable to excrete potassium effectively, leading to elevated levels in the blood. Hypertonic glucose with insulin helps shift potassium into the cells, reducing blood levels. Sodium bicarbonate can also help by correcting acidosis, which can worsen hyperkalemia. A: Hypernatremia involves high sodium levels, treated with fluid restriction or diuretics. B: Hypokalemia is low potassium levels, treated with potassium supplementation. D: Hypercalcemia is high calcium levels, treated with hydration and medications to lower calcium levels.

Correct Answer: A

Rationale: The correct answer is A: Blood supply to the stoma has been interrupted. A dusky appearance of the stoma indicates poor blood supply, which can lead to tissue ischemia and necrosis. This is a critical finding that requires immediate intervention to prevent further complications. In contrast, the other options are incorrect. Option B is incorrect because a dusky stoma is not a normal finding post-ileostomy surgery. Option C is incorrect as adjusting the ostomy bag will not address the underlying issue of compromised blood supply. Option D is incorrect as an intestinal obstruction would present with different symptoms and would not cause the stoma to appear dusky.

Correct Answer: C

Rationale: The correct answer is C because calling up the latest electrocardiogram results to check the client's progress breaches the client's confidentiality since this action involves disclosing the client's medical information to someone unauthorized to receive it. This violates the client's right to privacy and confidentiality. A, B, and D are incorrect: A: Giving a verbal report to the nurse on the telemetry unit is appropriate as it facilitates continuity of care and is within the scope of healthcare providers involved in the client's treatment. B: Notifying the on-call physician about a change in the client's condition is also essential for timely medical intervention and does not breach confidentiality. D: Updating the client's wife on his condition at his request is permissible as long as the client consents to sharing his medical information with his spouse.

Correct Answer: A

Rationale: Rationale: - Correct answer (A): Paco2 of 30 mm Hg is appropriate because lowering CO2 helps reduce ICP in clients with subdural hematoma. - Incorrect answer (B): Paco2 is not indicative of oxygenation status; it measures CO2 levels. - Incorrect answer (C): Paco2 of 30 mm Hg is low, not normal. - Incorrect answer (D): Paco2 of 30 mm Hg indicates hyperventilation, not hypoventilation.