A nurse is assisting a client who has received crutches in an urgent care center following a foot injury. Which of the following statements should the nurse identify as an indication that the client needs additional teaching?

“I will bear the weight of my body on my hands.”

"I have a set of my brother's old crutches in my basement I can also use."

“I will keep spare crutch tips handy.”

“I will inspect my crutches every day for signs of wear.”

Answer and Explanation

Correct Answer : A,B

Choice A rationale: Bearing the weight of the body on the hands is not the correct technique for using crutches. The weight should be borne on the arms, not the hands.
Choice B rationale: Using crutches that belonged to someone else may not be appropriate as they need to be properly fitted for the individual. Additionally, old crutches may be worn or damaged.
Choice C rationale: This statement is appropriate and does not indicate a need for additional teaching. Keeping spare crutch tips is a good practice, as crutch tips can wear down over time and may need replacement. This demonstrates the client's understanding of the need for maintenance and preparedness.
Choice D rationale: This statement is appropriate and indicates a good understanding of crutch care. Regular inspection of crutches is important to ensure their safety and effectiveness. It allows the client to identify any signs of wear or damage early on and take necessary actions, such as replacing worn-out parts, to prevent accidents or injuries.

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Correct Answer is B

Explanation

Choice A rationale: Inserting an indwelling urinary catheter is an invasive intervention and should be reserved for specific indications. It does not prevent skin breakdown.
Choice B rationale: Applying a moisture barrier ointment to the client's skin helps protect the skin from the harmful effects of urine and prevents breakdown.
Choice C rationale: Cleaning the client's skin and perineum with hot water after each episode of incontinence can lead to skin irritation and breakdown.
Choice D rationale: Checking the client's skin every 8 hours is not sufficient to prevent skin breakdown. Continuous assessment and prompt intervention are needed.

A. purulent B. serous C. sanguineous D. serosanguineous

Correct Answer is D

Explanation

Choice A rationale: Purulent drainage is thick and opaque, often indicating infection.
Choice B rationale: Serous drainage is thin and watery, typically clear or slightly yellow.
Choice C rationale: Sanguineous drainage is bright red and indicates fresh bleeding.
Choice D rationale: Serosanguineous drainage is thin and pale pink-yellow, representing a mixture of serous and sanguineous components.

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A nurse is assisting a client who has received crutches in an urgent care center following a foot injury. Which of the following statements should the nurse identify as an indication that the client needs additional teaching?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has urinary incontinence. Which of the following actions should the nurse implement to prevent the development of skin breakdown?

Correct Answer is B

Explanation

A nurse caring for a postoperative client observes the drainage in the client's closed wound drainage system. The drainage is thin with a pale pink-yellow color. The nurse documents the drainage as:

Correct Answer is D

Explanation

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