A nurse is assessing a client's ability to ambulate with crutches using a three-point gait. Which of the following actions should the nurse identify as a risk to the client's safety?

The client stands in a tripod position prior to walking.

The client keeps the elbows in a flexed position.

The client pushes downward on the handgrips.

The client places partial weight on the affected leg.

Answer and Explanation

The Correct Answer is D

A. Standing in a tripod position prior to walking with crutches is a correct stance to maintain balance and stability.
B. Keeping the elbows flexed helps absorb shock during ambulation and is appropriate when using crutches.
C. Pushing downward on the handgrips is necessary to generate upward force and support while using crutches.
D. Placing partial weight on the affected leg while ambulating with crutches using a three-point gait is incorrect and can jeopardize safety by potentially causing injury or instability.

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Correct Answer is C

Explanation

A. Providing assistance to the bathroom is appropriate but should follow assessment and intervention for urinary retention.
B. Increasing fluids may be beneficial but does not address the immediate need to assess for urinary retention.
C. Performing a bladder scan is the first action to assess if the client has urine in the bladder and needs further intervention.
D. Inserting a straight catheter is a potential intervention but should be based on assessment findings from the bladder scan.

A. A client who is being discharged to a long-term care facility B. A client who is postoperative following a lobectomy and has a chest tube C. A client who needs teaching about insulin self-administration D. A client who needs teaching prior to initiating cardiac rehabilitation activities

Correct Answer is B

Explanation

Rationale:
A. The float nurse may not be familiar with discharge planning specific to long-term care facilities.
B. A nurse from the PACU is highly experienced with postoperative care and monitoring of clients with chest tubes, making this the most appropriate assignment.
C. Teaching about insulin self-administration requires specific education techniques which the float nurse might not be most familiar with.
D. Teaching for cardiac rehabilitation involves specialized knowledge that might be outside the float nurse’s expertise.

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A nurse is assessing a client's ability to ambulate with crutches using a three-point gait. Which of the following actions should the nurse identify as a risk to the client's safety?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has not voided for 8 hr following the removal of an indwelling urinary catheter. Which of the following actions should be the nurse take first?

Correct Answer is C

Explanation

A nurse in the medical-surgical unit is assigning client care to a nurse who is floating from the PACU. The nurse should recognize that the float nurse is most qualified to care for which of the following clients?

Correct Answer is B

Explanation

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