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.

Answer and Explanation

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.

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Correct Answer is ["D","E"]

Explanation

Choice A reason: Oatmeal, cream of wheat, and pureed liquids are not clear liquids and are not appropriate for a clear liquid diet.
Choice B reason: Pureed beans, liquid protein supplements, and milkshakes are not considered clear liquids and should not be included in a clear liquid diet.
Choice C reason: Pureed carrots, creamed soup, and ice cream are not clear liquids because they are not transparent and cannot be consumed on a clear liquid diet.
Choice D reason: Carbonated drinks, gelatin, and broth are considered clear liquids because they are transparent and can be consumed on a clear liquid diet.
Choice E reason: Water, tea without milk or cream, and ice chips are clear liquids and are appropriate for a clear liquid diet.

A. Uses normal saline to irrigate the wound. B. Cleans from less soiled to more soiled areas. C. Opens a sterile package towards the body. D. Places soiled dressing in a plastic bag.

Correct Answer is C

Explanation

Choice A reason: Using normal saline to irrigate the wound is a correct practice and does not indicate a need for additional teaching. Normal saline is isotonic and is commonly used for wound irrigation because it does not interfere with the natural healing process.

Choice B reason: Cleaning from less soiled to more soiled areas is also a correct technique to prevent contamination of cleaner areas. This method helps to reduce the risk of infection and is a standard practice in wound care.

Choice C reason: Opening a sterile package towards the body is incorrect and indicates that additional teaching is needed. When opening a sterile package, it should be opened away from the body to maintain the sterility of the contents and prevent contamination.

Choice D reason: Placing soiled dressing in a plastic bag is a proper disposal method and does not indicate a need for additional teaching. It is important to properly dispose of soiled dressings to prevent the spread of infection.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

When conducting diet teaching for a client who is on a postoperative clear liquid diet, which foods should the nurse encourage the client to consume? Select all that apply.

Correct Answer is ["D","E"]

Explanation

A family member is demonstrating wound care using sterile technique. Which action indicates to the nurse that additional teaching is needed?

Correct Answer is C

Explanation

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?

A client who is admitted for malnutrition and severe dehydration receives a prescription for liquid feedings through a feeding tube. After the feeding tube is inserted and placement confirmed, which assessment is most important for the nurse to complete before starting the feeding?

An unlicensed assistive personnel (UAP) assigned to feed a client with meningococcal infection, for whom droplet precautions have been implemented, requests a change in assignment, reporting they have not yet been fitted for an N95 respirator mask. Which action should the nurse take?

While assisting a client with oral care, the nurse assesses the client's mouth. It is most important for the nurse to take action in response to which finding?

The nurse notes that a client has cyanosis of the toes and fingertips. Which vital sign should the nurse obtain first?

The nurse plans to encourage a group of young adult clients to engage in problem-solving strategies. Which action is most useful for the nurse to include during the teaching session?