💠 This option is correct because the proper cane height is measured from the client’s greater trochanter to the floor with the cane upright and the client wearing usual shoes.

💠 A correctly measured cane allows for about 15–30 degrees of elbow flexion, which promotes safe weight bearing and balance during ambulation.

💠 Having the cane at the correct height reduces strain on the shoulder and wrist, which can otherwise occur if the cane is too high or too low.

💠 For a client with right-sided weakness, the cane will be held in the left (strong) hand, but the length must still be appropriate to ensure safe gait.

💠 Proper cane fit is a foundational safety step before teaching sequence of steps, so ensuring it extends from the greater trochanter to the floor is a priority nursing action.

Have the client stand with feet close together for better balance.

💠 Standing with the feet close together actually decreases the base of support, which reduces stability rather than improves it.

💠 Clients with stroke and unilateral weakness need a wide base of support to help prevent falls.

💠 Narrow stance increases the risk of swaying and loss of balance, especially when also learning to use a cane.

💠 The nurse should instead encourage the client to stand with feet shoulder-width apart for safer posture and balance.

Stand on the left side of the cane when ambulating the client.

💠 For a client with right-sided weakness, the cane is held in the left hand, and the nurse should stand on the weaker (right) side for maximum safety support.

💠 Standing on the same side as the cane limits the nurse’s ability to support the weak side if the client loses balance.

💠 The nurse’s primary role during ambulation is to guard the affected side and prevent a fall, especially during early mobility.

💠 Therefore, standing on the left side of the cane is not the safest positioning for this stroke client.

Have the client move the cane forward and take a step with the left foot.

💠 With right-sided weakness, the cane is held in the left hand but should be moved with the weak (right) leg, not the strong left leg.

💠 The correct gait sequence is cane → weak leg → strong leg, which helps offload weight from the affected side.

💠 Stepping forward with the left (strong) foot after moving the cane disrupts the proper gait pattern and can increase fall risk.

💠 This option reflects incorrect teaching of cane use for a client with unilateral weakness.

🔷 This option is correct because active ROM involves the client moving their own joints through a comfortable range without causing pain.

🔷 The instruction to stop when resistance is felt protects the joint, ligaments, and muscles from overextension or injury.

🔷 ROM exercises are intended to maintain joint flexibility, circulation, and function, not to push beyond normal limits.

🔷 Stopping at resistance respects the client’s functional limit and helps prevent muscle strain, ligament damage, or joint inflammation.

🔷 This teaching promotes safe, therapeutic exercise and is appropriate for independent performance by the client.

Perform exercises until you feel pain in the joint.

🔷 Pain is a warning sign that tissue is being stressed or injured, so continuing until pain occurs is not safe.

🔷 Active ROM should be pain-free or only mildly uncomfortable, never deliberately painful.

🔷 Instructing clients to move until pain may cause inflammation, joint damage, or exacerbation of existing conditions such as arthritis.

🔷 Nurses teach clients that pain is a signal to stop, not a goal of effective exercise.

Perform exercises rapidly to increase muscle strength.

🔷 ROM exercises are designed to maintain flexibility and prevent stiffness, not primarily to build strength through rapid repetition.

🔷 Fast or jerky movements can increase the risk of injury to joints, tendons, and muscles.

🔷 Safe ROM should be performed in a slow, controlled, and smooth manner to promote circulation and comfort.

🔷 Rapid exercise is not appropriate in most therapeutic ROM programs, especially for older or debilitated clients.

Expose the entire body to observe overall movement.

🔷 While observation is important, maintaining client privacy and dignity is a critical nursing responsibility.

🔷 Only the area or joint being exercised should be exposed, with the rest of the body properly draped.

🔷 Full body exposure is unnecessary and inappropriate for routine ROM teaching.

🔷 Protecting modesty and comfort builds trust and supports therapeutic interaction.

🟦 Initiating a bed alarm system is the safest and least restrictive first intervention, which aligns with fall-prevention best practices.

🟦 The alarm gives immediate notification when the confused client attempts to get out of bed, reducing the likelihood of an unassisted fall.

🟦 This action can be performed independently by the nurse and does not require a provider’s order, allowing for rapid implementation.

🟦 Bed alarms support continuous monitoring, especially when the client has impaired judgment or cannot call for help.

🟦 This intervention preserves client autonomy while still ensuring safety, making it the most appropriate first step.

Sit the client at the nurses' station

🟦 Sitting the client at the nurses’ station may offer short-term supervision, but it does not provide consistent monitoring, especially during busy periods.

🟦 This strategy exposes the client to a high-stimulation environment, which may worsen confusion or agitation.

🟦 It is less reliable than an alarm system because nurses cannot observe the client continuously.

🟦 Moving the client frequently may increase fall risk during transfers.

🟦 It is not the safest or most efficient initial intervention compared to activating a bed alarm.

Place the client in soft wrist restraints

🟦 Restraints are considered a last resort and are among the most restrictive fall-prevention measures.

🟦 They require a provider order, strict monitoring, and documentation, so they cannot be applied immediately.

🟦 Restraints increase the risk of injury, agitation, and psychological distress, especially in confused clients.

🟦 Using restraints first violates the principle of implementing the least restrictive option.

🟦 They should only be considered after all other safety methods fail, making this an inappropriate first action.

Ask the healthcare provider for a sedative

🟦 Sedatives increase the risk of oversedation, respiratory depression, and paradoxical agitation in confused clients.

🟦 They do not prevent falls and may actually increase instability and delirium.

🟦 Medication is not a first-line fall intervention due to significant safety and ethical concerns.

🟦 Sedation masks changes in neurological status, making assessment more difficult.

🟦 Nonpharmacologic interventions must be attempted first before considering sedatives.

🟩 Washing the affected area immediately is the first and most urgent action after a needlestick injury.

🟩 Cleansing reduces surface contamination, lowering initial exposure risk to bloodborne pathogens.

🟩 This action aligns with OSHA and CDC exposure-control guidelines, which emphasize immediate wound cleaning.

🟩 It is the only action that directly addresses biological contamination at the moment it occurs.

🟩 All other steps in the protocol rely on completing this initial first-aid step, making it the top priority.

Apply a bandage and monitor the puncture site.

🟩 While bandaging is appropriate after washing, doing so first traps contaminants inside.

🟩 Monitoring without cleansing does nothing to remove pathogenic material on the skin.

🟩 This option overlooks the critical need for immediate decontamination.

🟩 Covering the wound prematurely increases the risk of local infection.

🟩 This is a secondary step, not the priority action.

Ask the client if they have any known infections.

🟩 Asking about infection status is part of post-exposure assessment, but it is not immediate first aid.

🟩 Relying on client self-report is inaccurate because many infections such as HIV or hepatitis B/C may be unknown to the client.

🟩 Delaying washing to ask questions increases the period of exposure risk.

🟩 The source patient's status is later verified through formal protocols, not informal questioning.

🟩 This step occurs after the nurse has addressed their own safety.

Complete an incident report.

🟩 Completing an incident report is required but occurs after first aid, not before.

🟩 Documentation does not reduce contamination or protect the nurse from bloodborne pathogens.

🟩 It is an administrative task that is part of the follow-up, not immediate care.

🟩 Delaying washing to document increases unnecessary exposure time.

🟩 Because it does not address immediate risk, it is not the priority.

✳️A paralyzed client cannot safely stand, transfer, or participate in out-of-bed bathing, requiring a complete bed bath.

✳️This method ensures thorough hygiene without risking falls or musculoskeletal injury.

✳️A bed bath allows the nurse to assess skin integrity, especially high-risk areas for pressure injury.

✳️It promotes comfort while accommodating limited mobility and functional deficits.

✳️Complete bed baths are the safest daily hygiene method for clients with new or total paralysis.

Sponge bath at sink

✳️This requires the client to sit upright and maintain posture, which is unsafe for a paralyzed individual.

✳️Attempting to transfer the client to a sink increases risk of falls.

✳️Many paralyzed clients cannot support their trunk or head, making this option inappropriate.

✳️The sink area lacks the necessary safety equipment for paralyzed clients.

✳️This method does not match the client’s functional limitations.

Tub bath with chair

✳️Tub transfers are extremely dangerous for clients with complete or new paralysis.

✳️Even with a chair, the environment is slippery, increasing risk of injury.

✳️Tub baths require significant upper-body strength and stability, which the client does not have.

✳️Tub bathing is usually reserved for clients in later rehabilitation, not acute paralysis.

✳️This option does not ensure adequate safety or support.

Shower with chair

✳️Shower chairs require the client to maintain seated balance, which many newly paralyzed clients cannot do.

✳️Transferring to the shower area poses high fall risk.

✳️Shower water increases the chance of slipping or sliding, even with a chair.

✳️Many paralyzed clients cannot tolerate prolonged sitting due to orthostatic issues.

✳️This is not the safest option for daily bathing immediately after paralysis.

🔶Rectal temperature provides the most accurate reflection of core body temperature, making it the clinical gold standard.

🔶It is less affected by factors such as mouth breathing, environmental temperature, or sweating.

🔶This method is essential when precise readings are required, such as in infants, hypothermia, or critical illness.

🔶Rectal measurements remain stable and reliable across different clinical conditions.

🔶Because it directly measures internal body heat, it surpasses axillary, oral, and skin methods in accuracy.

Axillary

🔶Axillary readings are often lower and less accurate because they measure surface temperature.

🔶The value can vary greatly depending on room temperature and whether the axilla is sealed.

🔶This method frequently underestimates core temperature, especially in infants.

🔶It is used more for screening and is not recommended for highly accurate assessment.

🔶Therefore, it is less reliable than rectal temperature.

Skin

🔶Skin thermometers measure surface temperature, which fluctuates with environmental exposure, sweating, and device placement.

🔶They can be convenient but have the lowest reliability compared to core-temperature methods.

🔶These readings often differ significantly from internal temperature, especially in illness or fever.

🔶Skin temperatures are best for quick checks but not diagnostic accuracy.

🔶They do not provide a dependable measure of core temperature.

Oral

🔶Oral temperatures are affected by recent eating, drinking, smoking, or mouth breathing.

🔶They require client cooperation and proper technique to ensure accuracy.

🔶Oral readings often differ from core temperature by 0.3–0.6°C.

🔶This variability makes oral measurements less accurate in many clinical conditions.

🔶They are useful but not the most accurate option compared to rectal temperature.

Encourage the client to participate if possible.

🔷 Encouraging participation helps maintain the client’s independence, even when they are immobile.

🔷 Even small actions, such as washing their face or holding a washcloth, help preserve muscle strength and prevent total dependency.

🔷 This promotes psychological well-being, reducing feelings of helplessness or loss of dignity.

🔷 Involving the client supports client-centered care, ensuring the nurse respects the client’s abilities and preferences.

🔷 Participation also helps the nurse assess the client’s functional capacity, fatigue level, and response to activity.

Maintain the client’s privacy.

🔷 Maintaining privacy is essential for dignity, comfort, and emotional safety during hygiene care.

🔷 Immobile clients are particularly vulnerable, making privacy a critical part of therapeutic communication and trust.

🔷 Covering body areas not being washed prevents unnecessary exposure and reduces embarrassment or anxiety.

🔷 Respecting privacy reinforces professional nursing conduct and supports the client’s human rights and autonomy.

🔷 This action aligns with safety and ethical standards in all forms of intimate care.

Change washcloths as needed during bathing.

🔷 Changing washcloths prevents cross-contamination, especially when cleaning different body areas.

🔷 This practice reduces the spread of bacteria, secretions, or debris, lowering infection risk.

🔷 Clean cloths protect fragile skin and support healthy skin integrity, especially in immobile clients prone to breakdown.

🔷 Using separate cloths also prevents the nurse from inadvertently moving contaminants from dirty to clean areas.

🔷 This aligns with safe hygiene principles used in all bed bath procedures.

Keep the room warm during bathing.

🔷 Immobile clients often experience temperature fluctuations, so a warm room prevents chilling during bathing.

🔷 Warm environments promote comfort and relaxation, reducing stress during hygiene care.

🔷 Maintaining warmth prevents shivering, which increases metabolic demand and energy expenditure—important in frail or weak clients.

🔷 A warm environment also supports more effective skin cleansing because muscles are relaxed.

🔷 This action aligns with general principles of safe, therapeutic client care during bathing.

Wash the client's legs and perineum first.

🔷 Washing the legs and perineum first is incorrect because bathing should proceed from cleanest to dirtiest areas.

🔷 Starting at the perineum increases the risk of spreading bacteria or contaminants to cleaner areas like the face or trunk.

🔷 The perineal region is considered one of the most contaminated body areas, requiring cleansing toward the end of the bath.

🔷 Proper sequence supports infection prevention and ensures the nurse maintains a safe hygiene routine.

🔷 Therefore, this option contradicts the principles of clean-to-dirty bathing technique.

🔷 This is the priority because neutropenia severely weakens the immune system, making even mild infections potentially life-threatening.

🔷 Asking about sick contacts in the household is essential to identify whether the client is being exposed to viruses, bacteria, or respiratory infections that could cause sepsis.

🔷 Older adults with neutropenia are at extreme risk because they may show subtle or no fever, meaning early identification of exposure is critical.

🔷 Determining potential environmental infection sources helps the nurse implement isolation measures, reinforce infection-control teaching, and protect the client.

🔷 This assessment directly affects survival and prevention of complications, making it the first and most urgent question.

“Can you rate your pain on a scale of 0–10?”

🔷 Pain assessment is important but is not the priority in a neutropenic client unless paired with signs of infection.

🔷 Pain alone does not indicate immediate threat, whereas exposure to infectious individuals can quickly lead to systemic infection.

🔷 Neutropenic clients may deteriorate rapidly even without major symptoms, so focusing on infection exposure is more urgent.

🔷 This question does not immediately address life-threatening risks associated with neutropenia.

🔷 It is appropriate later, but not as the first priority question.

“Can you tell me where you are currently?”

🔷 This assesses orientation, which is important but not the immediate danger for a neutropenic client.

🔷 Confusion is not expected unless the client is already septic, which must first be assessed through infection-related questioning.

🔷 Orientation checks do not address the client’s large vulnerability to pathogens in the home.

🔷 While safety is important, it is secondary to identifying potential infectious exposures.

🔷 This question is appropriate but not the first priority.

“How long ago was your last bowel movement?”

🔷 While constipation can be important in older adults, it is not the priority in neutropenia, where infection and exposure risks take precedence.

🔷 Bowel movement patterns do not determine exposure to pathogens in the environment.

🔷 This assessment is more relevant to mobility, hydration, or medication effects, not immediate safety.

🔷 Infection risk outweighs digestive concerns in the acute assessment.

🔷 Therefore, this question should be asked later, not as the priority.

🟩 This client has impaired oxygenation, and an SpO₂ of 91% on room air indicates acute respiratory compromise.

🟩 Dyspnea with low oxygen saturation requires immediate intervention because inadequate oxygenation can rapidly lead to hypoxemia, confusion, and respiratory failure.

🟩 Airway and breathing issues always take priority according to the ABCs (Airway, Breathing, Circulation).

🟩 Even a small decline in respiratory status can quickly become life-threatening, so the nurse must assess this client first.

🟩 This client requires prompt actions such as oxygen supplementation, lung assessment, and positioning, making them the highest priority.

A client with a heart rate of 115 after working with physical therapy

🟩A heart rate of 115 after activity is expected due to exercise-related tachycardia and typically resolves with rest.

🟩This client has no signs of instability such as chest pain, SOB, or hypotension.

🟩Activity-induced increases in heart rate are not considered an immediate threat.

🟩Compared to airway compromise, mild tachycardia does not require immediate nursing intervention.

🟩This client can be safely assessed later.

A client with painful urination and a temperature of 100.4°F (38°C)

🟩This client likely has a UTI, which is important but not immediately life-threatening.

🟩A fever of 100.4°F is considered low-grade and does not indicate sepsis at this point.

🟩They are stable and do not show signs of airway or circulation failure.

🟩While they need evaluation, they do not require the same urgency as a client with respiratory impairment.

🟩Thus, this client is not the first priority.

A client with a blood pressure of 108/63 mmHg feeling lightheaded

🟩A BP of 108/63 mmHg is within a normal range, though slightly low, and may explain the lightheadedness.

🟩This client is symptomatic but stable, and immediate life-threatening deterioration is unlikely.

🟩The nurse may need to check orthostatic vitals or hydration status, but not urgently.

🟩Compared to respiratory compromise, mild hypotension ranks lower in priority.

🟩This client should be seen after stabilizing the client with oxygenation issues.