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 D

Explanation

A. Notifying the provider is necessary but not the first action.
B. Applying a cold pack may help with swelling but is not the first action to take.
C. Removing the PICC line should only be done after assessing the situation and consulting with the provider.
D. Measuring the circumference of both upper arms is the first action to assess the extent of the swelling and compare it to the other arm, which will help determine the severity of the issue.

A. Urine-specific gravity greater than 1.030 B. Bounding pulse C. Swelling at the IV site D. Crackles upon auscultation E. Pitting edema

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

Explanation

A. Urine-specific gravity greater than 1.030 indicates concentrated urine, suggesting dehydration, not fluid volume excess.
B. A bounding pulse is a sign of fluid volume excess.
C. Swelling at the IV site indicates infiltration, not systemic fluid volume excess.
D. Crackles upon auscultation of the lungs indicate fluid accumulation in the lungs, a sign of fluid volume excess.
E. Pitting edema is a sign of fluid volume excess, indicating fluid retention in the tissues.

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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 is receiving total parenteral nutrition via a peripherally inserted central catheter (PICC). When assessing the client, the nurse notes swelling of the client's arm above the PICC insertion site. Which of the following actions should the nurse take first?

Correct Answer is D

Explanation

A nurse is assessing an older adult client who is receiving IV therapy. The nurse should recognize that which of the following findings indicates fluid volume excess? (Select all that apply.)

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

Explanation

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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?

A nurse is caring for a client who has impaired renal function. For which of the following findings should the nurse notify the provider?

A nurse is teaching an adult client who has a low literacy level about self administration of a subcutaneous medication. Which of the following strategies should the nurse use to promote the client's understanding?

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