A client with a sprained ankle is seen at the clinic and is given a pair of crutches. When the client stands with the aid of the crutches, the nurse notes a space of three finger widths between the top of the crutch and the client's axilla. Which action should the nurse take?
Confer with the physical therapist for correct crutch size.
Ask the client to sit down while the crutch length is adjusted.
Assess the client for signs of diminished circulation in the hands.
Proceed with teaching the client how to walk with the crutches.
The Correct Answer is D
The correct answer is choice d. Proceed with teaching the client how to walk with the crutches.
Choice A rationale:
Confer with the physical therapist for correct crutch size. This is unnecessary because the crutches are already correctly fitted. A space of three finger widths between the top of the crutch and the client’s axilla is appropriate to prevent pressure on the axilla and potential nerve damage.
Choice B rationale:
Ask the client to sit down while the crutch length is adjusted. This action is not needed since the crutches are already properly adjusted. Adjusting the crutch length further could lead to improper fitting, which might cause discomfort or injury.
Choice C rationale:
Assess the client for signs of diminished circulation in the hands. While assessing circulation is important, it is not directly related to the fitting of the crutches. Proper crutch fitting focuses on ensuring there is no pressure on the axilla and that the client can use the crutches comfortably.
Choice D rationale:
Proceed with teaching the client how to walk with the crutches. This is the correct action because the crutches are already properly fitted. The nurse should now focus on educating the client on the correct use of the crutches to ensure safe and effective mobility.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A reason: Drinking 800 to 1,000 milliliters of fluid daily is below the recommended intake for most adults, which is generally around 2,000 milliliters per day to help prevent constipation.
Choice B reason: Oxycodone is an opioid that can actually lead to constipation, and its use should be carefully managed, not necessarily taken as scheduled for this purpose.
Choice C reason: Adding fat-containing foods is not a standard recommendation for preventing constipation; instead, a high-fiber diet is usually advised.
Choice D reason: Early and frequent ambulation is encouraged postoperatively to help stimulate bowel function and prevent constipation.
Correct Answer is C
Explanation
Choice A reason: Giving water may be necessary, but it is not the first intervention if there is a concern about urinary output.
Choice B reason: Notifying the healthcare provider is important but should occur after initial assessments and interventions.
Choice C reason: Checking for a kink in the drainage tubing is a quick and simple intervention that may resolve the issue of low output.
Choice D reason: Reviewing the intake and output record is important for understanding the patient's fluid status but is not the first action to take in this situation.
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