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A nurse is instructing a client whose left leg is in a cast on how to use crutches. Which statement from the client indicates they have understood the instructions?

“When descending stairs, I will first shift my weight to my right leg.”.

“I should place my crutches 12 inches in front and to the side of each foot.”.

“As I sit down, I will hold one crutch in each hand.”.

“I will make sure the shoulder rests are snug against my body.”. .

Answer and Explanation

The Correct Answer is B

Choice A rationale

When descending stairs, the crutches and the injured leg should go down first, followed by the good leg31415.

Choice B rationale

Placing crutches 12 inches in front and to the side of each foot is a correct method for using crutches. This provides stability and balance while walking31415.

Choice C rationale

When sitting down, it’s recommended to hold both crutches in one hand on the same side as the injured leg. This allows the other hand to be free to reach for the chair31415.

Choice D rationale

The shoulder rests, or pads, should not be snug against the body. There should be a space of about 1-2 inches between the top of the crutch and the armpit31415.

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Correct Answer is A

Explanation

Choice A rationale

Using a bed exit alarm system is a common intervention to minimize the risk of injury in patients with dementia. These systems alert staff when a patient attempts to leave the bed, allowing for timely intervention to prevent falls.

Choice B rationale

Raising four side rails while the patient is in bed is not a recommended practice. This could be considered a form of restraint and could increase the risk of injury if the patient attempts to climb over the rails.

Choice C rationale

Applying one soft wrist restraint is not a recommended practice for patients with dementia. Restraints should be used as a last resort and only when necessary for the patient’s safety.

Choice D rationale

Dimming the lights in the patient’s room is not a recommended practice to minimize the risk of injury in patients with dementia. Adequate lighting can help prevent falls and other accidents.

A. Use a resuscitation bag with 80% oxygen prior to the procedure. B. Select a suction catheter that is half the size of the lumen. C. Place the end of the suction catheter in water-soluble lubricant. D. Adjust the wall suction apparatus to a pressure of 170 mm Hg.

Correct Answer is B

Explanation

Choice A rationale: Using a resuscitation bag with 80% oxygen prior to the procedure is inappropriate. While pre-oxygenation is important before suctioning to prevent hypoxia, the oxygen concentration should be 100%, not 80%. Normal oxygen saturation levels are 95% to 100%. Pre-oxygenating with 100% oxygen ensures the patient maintains adequate oxygenation during the brief suctioning period. Using 80% oxygen does not fully optimize oxygen reserves for this purpose.

Choice B rationale: Selecting a suction catheter that is half the size of the tracheostomy lumen is appropriate. This size prevents excessive occlusion of the airway, ensuring adequate airflow during suctioning. The correct catheter size minimizes trauma to the tracheal mucosa and prevents hypoxia. The catheter should not exceed 50% of the tracheostomy diameter to maintain proper airway function, making this the correct action for safe and effective suctioning.

Choice C rationale

Placing the end of the suction catheter in water-soluble lubricant is not recommended. This could introduce bacteria into the airway and increase the risk of infection.

Choice D rationale

Adjusting the wall suction apparatus to a pressure of 170 mm Hg is not correct. The recommended suction pressure for adults is usually between 80 and 120 mm Hg. Suctioning at too high a pressure can cause trauma to the airway.

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A nurse is instructing a client whose left leg is in a cast on how to use crutches. Which statement from the client indicates they have understood the instructions?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a patient who has dementia. What intervention should the nurse take to minimize the risk of injury to the patient?

Correct Answer is A

Explanation

A nurse is preparing to suction secretions from a patient who has a new tracheostomy. Which of the following actions should the nurse plan to take?

Correct Answer is B

Explanation

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