A nurse is assessing a client who is using crutches as an assistive device due to a right hip fracture. Which of the following actions should the nurse take prior to planning the client's care?
Observe the client's ability to keep their elbows extended when using the crutches.
Instruct the client to lean forward when using the crutches.
Observe the client's gait pattern when using the crutches.
Ensure the client's weight is placed on their axilla area when using the crutches.
The Correct Answer is C
A. Observe the client's ability to keep their elbows extended when using the crutches: The elbows should be slightly flexed, not fully extended, when using crutches. Observing for elbow extension is incorrect and could indicate improper technique. Proper elbow positioning is assessed as part of gait evaluation rather than as a standalone measure.
B. Instruct the client to lean forward when using the crutches: Leaning forward places excessive pressure on the axillae and increases the risk of nerve injury. Clients should maintain an upright posture while using crutches, so this instruction is unsafe and should not be included in care planning.
C. Observe the client's gait pattern when using the crutches: Observing the gait pattern allows the nurse to assess how the client distributes weight, coordinates movements, and uses the crutches safely. This assessment is essential prior to planning care and interventions, ensuring that the client can ambulate safely and independently.
D. Ensure the client's weight is placed on their axilla area when using the crutches: Weight should be supported by the hands and arms, not the axillae, to prevent nerve damage. Ensuring proper weight distribution is part of teaching and assessment, but placing weight on the axillae is incorrect and unsafe.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Monitor the dorsalis pedis pulse every 15 min: Frequent assessment of peripheral pulses, such as the dorsalis pedis, is essential after a cardiac catheterization to detect early signs of arterial occlusion, bleeding, or compromised circulation. Monitoring every 15 minutes during the initial post-procedure period allows timely identification of complications.
B. Place the client in Fowler's position: After a femoral cardiac catheterization, the client is typically positioned supine with the affected leg straight to minimize bleeding and hematoma formation. Fowler’s position can increase stress on the groin puncture site and is not recommended immediately post-procedure.
C. Keep the client NPO for 24 hr: NPO status is not routinely required for 24 hours following cardiac catheterization. Clients may resume oral intake as tolerated once hemodynamically stable, unless contraindicated for other medical reasons.
D. Maintain strict bedrest for the first 12 hr: While bedrest is necessary immediately post-procedure, strict immobility is usually required for 2–6 hours, depending on the type of closure device or sheath used. Maintaining 12 hours of strict bedrest is longer than standard protocol and may unnecessarily increase discomfort and risk of complications like urinary retention.
Correct Answer is A
Explanation
A. "What part of this assignment makes you upset?": This response encourages open communication, allowing the staff nurse to express specific concerns. It demonstrates active listening, validation of feelings, and promotes problem-solving in a professional and supportive manner.
B. "Let's discuss how this affects your performance improvement plan.": This response shifts the focus to evaluation or discipline rather than addressing the immediate concern. It may create defensiveness and does not validate the nurse’s feelings or allow for discussion of the assignment issue.
C. "Why are you talking to me instead of the charge nurse?": This response is dismissive and may discourage the staff nurse from voicing concerns in the future. It does not address the fairness of the assignment or explore potential solutions.
D. "You are not the only one with a heavy assignment today.": Comparing workloads minimizes the nurse’s concerns and can be perceived as unsupportive. It does not facilitate problem-solving or acknowledge the staff nurse’s feelings about the assignment.
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