A nurse is assessing a client who is postoperative following abdominal surgery and has an indwelling urinary catheter that is draining dark yellow urine at 25 mL/hr.

Which of the following interventions should the nurse anticipate?

The correct answer is b. Remove the device from the room.

Choice A rationale:

• Reporting the defect to the equipment maintenance staff is essential,but it's not the immediate priority.The primary concern is to eliminate the safety hazard posed by the frayed cord to prevent potential harm to the client and others.
• Delaying the removal of the device could lead to electrical shock,fire,or other serious consequences.
• Therefore,removing the device from the room takes precedence over reporting the defect.

Choice B rationale:

• Removing the device from the room is the most appropriate first action because it:
  • Eliminates the immediate safety hazard.
  • Prevents potential harm to the client and others.
  • Protects the device from further damage.
  • Ensures the safety of the environment.
  • Demonstrates the nurse's prioritization of patient safety.

Choice C rationale:

• Initiating a requisition for a replacement CPM device is necessary to ensure the client's continued treatment.
• However,it's not the first action because it doesn't address the immediate safety concern.
• The nurse should first remove the faulty device and then initiate the process for obtaining a replacement.

Choice D rationale:

• Ensuring the device inspection sticker is current is a vital part of equipment maintenance.
• However,it's not relevant to the immediate safety issue of the frayed cord.
• The presence of a current inspection sticker doesn't guarantee the device's safety or functionality at that moment.
• The nurse must prioritize removing the hazard and then follow up with appropriate documentation and reporting.

The correct answer is Choice d. Positioning both hands on the grips with his elbows slightly flexed.

Choice A rationale:

• Moving both crutches with the stronger leg forward first is incorrect for a three-point gait.This describes a two-point gait,which is used when a client can bear weight on both legs.In a three-point gait,the client bears weight on the unaffected leg and the crutches,not the stronger leg.
• This action would put excessive weight on the affected leg and could potentially compromise healing or cause further injury.

Choice B rationale:

• Supporting his body weight while leaning on the axillary crutch pads is also incorrect.This can lead to nerve damage in the armpits and should be avoided.
• The weight should be distributed through the hands and wrists,not the armpits.

Choice C rationale:

• Stepping with his affected leg first when going up stairs is incorrect and potentially dangerous.The client should lead with the stronger leg when going up stairs to maintain balance and control.

Choice D rationale:

• Positioning both hands on the grips with his elbows slightly flexed is the correct action for using crutches with a three-point gait.This allows for proper weight distribution,balance,and control of the crutches.
• It also helps to prevent fatigue and strain in the arms and shoulders.

Key points to remember about the three-point gait:

• Weight is borne on the unaffected leg and the crutches,not the affected leg.
• The crutches and the unaffected leg move forward together,followed by the affected leg.
• The client should look ahead,not down at their feet.
• The client should take small,even steps.
• The client should rest as needed.