A nurse is assisting with the ambulation of a client with the use of a gait belt, who becomes light-headed and begins to fall. Which of the following actions should the nurse take?

extend one leg and allow the client to slide down the leg to the floor.

move both feet together when the client begins to fall

wrap both arms around the client's arm and shoulders

protect the client's extremities while lowering them to the floor.

Answer and Explanation

The Correct Answer is A

A. Extend one leg and allow the client to slide down the leg to the floor.

It helps to control the fall, protects the client from injury, and allows the nurse to safely guide the client to the floor without using excessive force.

B. Move both feet together when the client begins to fall.

Keeping the feet together reduces stability and increases the risk of both the client and nurse falling.

C. Wrap both arms around the client's arm and shoulders.

This could cause injury to the client’s upper body and doesn't provide support for a safe fall.

D. Protect the client's extremities while lowering them to the floor.

While protecting extremities is important, the nurse’s primary action should be to use proper body mechanics (like extending one leg) to safely lower the client.

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Correct Answer is D

Explanation

A. The pads should be 1/2 to 2 inches (1.3cm to 5cm) below the axilla

This is true and helps avoid pressure on the axilla and nerves.

B. When walking, the patient will need to straighten the elbow and the wrist during weight bearing

Elbows should be slightly flexed (~15–30 degrees); straightening the elbow and wrist fully can cause injury and reduce control.

C. Resting the body's weight on the axillary bar does not put pressure on vital nerves which can occlude blood vessels in the axilla causing permanent or temporary damage

Resting on the axillary bar can compress the brachial plexus and axillary vessels, causing nerve damage or paralysis.

D. They will need to be adjusted in both overall length and from the axillary bar to the handgrip

Proper crutch fitting includes adjusting both the overall length and the handgrip height.

A. Turn their foot and leg away from their other leg B. Move their left forward and up C. Move their leg medially toward their other leg D. Move their leg behind their body

Correct Answer is D

Explanation

A. Turn their foot and leg away from their other leg

This movement is called external rotation, not hyperextension.

B. Move their leg forward and up

This action is flexion of the hip.

C. Move their leg medially toward their other leg

This describes adduction, moving the limb toward the body's midline.

D. Move their leg behind their body

Hyperextension of the hip involves moving the leg backward beyond the normal range of extension.

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A nurse is assisting with the ambulation of a client with the use of a gait belt, who becomes light-headed and begins to fall. Which of the following actions should the nurse take?

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Naxlex Comprehensive Predictor Exams

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