A nurse is providing teaching about the use of crutches using a three-point gait to a client who has a tibia fracture.
Which of the following actions by the client indicates an understanding of the teaching?
Moving both crutches with the stronger leg forward first.
Supporting his body weight while leaning on the axillary crutch pads
Stepping with his affected leg first when going up stairs
Positioning both hands on the grips with his elbows slightly flexed.
The Correct Answer is D
The correct answer is Choice d. Positioning both hands on the grips with his elbows slightly flexed.
Choice A rationale:
- Moving both crutches with the stronger leg forward first is incorrect for a three-point gait. This describes a two-point gait, which is used when a client can bear weight on both legs. In a three-point gait, the client bears weight on the unaffected leg and the crutches, not the stronger leg.
- This action would put excessive weight on the affected leg and could potentially compromise healing or cause further injury.
Choice B rationale:
- Supporting his body weight while leaning on the axillary crutch pads is also incorrect. This can lead to nerve damage in the armpits and should be avoided.
- The weight should be distributed through the hands and wrists, not the armpits.
Choice C rationale:
- Stepping with his affected leg first when going up stairs is incorrect and potentially dangerous. The client should lead with the stronger leg when going up stairs to maintain balance and control.
Choice D rationale:
- Positioning both hands on the grips with his elbows slightly flexed is the correct action for using crutches with a three-point gait. This allows for proper weight distribution, balance, and control of the crutches.
- It also helps to prevent fatigue and strain in the arms and shoulders.
Key points to remember about the three-point gait:
- Weight is borne on the unaffected leg and the crutches, not the affected leg.
- The crutches and the unaffected leg move forward together, followed by the affected leg.
- The client should look ahead, not down at their feet.
- The client should take small, even steps.
- The client should rest as needed.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
This is because varicella, or chickenpox, is a highly contagious disease caused by the varicellazoster virus (VZV), which can spread through the air or by direct contact with the fluid from the blisters. A negative air pressure room prevents the air from the room from circulating to other areas of the hospital, reducing the risk of transmission to other patients and staff.
Choice A is wrong because aspirin should not be given to children with chickenpox, as it can cause a serious condition called Reye’s syndrome, which affects the brain and liver. Instead, acetaminophen can be used to reduce fever.
Choice B is wrong because droplet precautions are not enough to prevent the spread of chickenpox. Droplet precautions involve wearing a mask and gloves when in close contact with the patient, but they do not prevent the virus from traveling through the air. Airborne precautions, which include a negative air pressure room and wearing a respirator, are needed for chickenpox.
Choice D is wrong because Koplik spots are not a sign of chickenpox, but of measles, another viral infection that causes a rash. Chickenpox causes an itchy rash with small, fluid-filled blisters that crust over.
Correct Answer is D
Explanation
The correct answer is choice D. The nurse should choose a vein that is palpable and straight for IV catheter insertion.
This will facilitate the insertion of the catheter and reduce the risk of complications such as infiltration, phlebitis, or hematoma. A straight vein will also allow the catheter to be inserted up to the hub, which reduces the risk of contamination along the length of the catheter.
Choice A is wrong because selecting a site on the client’s dominant arm can interfere with the client’s mobility and increase the risk of dislodging the catheter. The nurse should choose a site on the client’s non-dominant arm, preferably on the hand or forearm.
Choice B is wrong because applying a tourniquet below the venipuncture site will impede blood flow and make it harder to locate a suitable vein. The nurse should apply a tourniquet above the venipuncture site, about 10 to 15 cm from the insertion site.
Choice C is wrong because elevating the client’s arm prior to insertion will decrease venous filling and make it harder to palpate a vein. The nurse should lower the client’s arm below the level of the heart to increase venous distension.
Normal ranges for IV catheter size and insertion angle depend on several factors, such as the type and duration of therapy, the condition and size of the vein, and the age and preference of the client.
In general, smaller gauge catheters (20 to 24) are preferred for peripheral IV therapy, and larger gauge catheters (14 to 18) are used for rapid fluid administration or blood transfusion. The insertion angle can vary from 10 to 30 degrees, depending on the depth and location of the vein.
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