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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

Stepping with his affected leg first when going up stairs

Positioning both hands on the grips with his elbows slightly flexed

Supporting his body weight while leaning on the axillary crutch pads

Answer and Explanation

The Correct Answer is C

The correct answer is a. Moving both crutches with the stronger leg forward first.

Rationale for Choice C:

Proper positioning of the hands on the grips and keeping the elbows slightly flexed helps ensure stability and control while using the crutches.

Rationale for Other Choices:

a. In a three-point gait, the client moves both crutches and the affected leg together, followed by the unaffected leg. The stronger leg does not move forward first.

b. Stepping with the affected leg first when going up stairs: This action is incorrect for the three-point gait. When ascending stairs, the client should move the stronger leg up first, followed by the crutches and the affected leg.

d. Supporting his body weight while leaning on the axillary crutch pads: This action is also correct for general crutch use, but it does not specifically address the weight-bearing restrictions and movement pattern of the three-point gait.

Additional Information:

Practice and supervision: It's essential for the client to practice the three-point gait under the supervision of a healthcare professional to ensure proper technique and safety.
Gradual progression: The client should gradually increase their distance and duration of crutch use as their strength and coordination improve.
Pain management: Adequate pain management is crucial to allow the client to participate in rehabilitation and regain mobility.

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Correct Answer is D

Explanation

A. Incorrect. This client is immobile but not at immediate risk from fire.
B. Incorrect. While a bedridden client wearing a hearing aid requires assistance, they are not in immediate danger like a client in traction.
C. Incorrect. A client using a wheelchair and being confused requires assistance, but the urgency is not as high as with a client in traction.
D. Correct. Oxygen is a highly combustible gas, and any spark or open flame near an oxygen source can ignite a fire. Therefore, clients receiving oxygen are at the highest risk during a fire.

A. Changing the inner cannula on a tracheostomy. B. Inserting a tunneled central venous catheter. C. Irrigation of an external ear canal. D. Administering a platelet transfusion.

Correct Answer is B

Explanation

Choice A rationale:

Changing the inner cannula on a tracheostomy is within the legal scope of practice for registered nurses. Nurses are trained to perform tracheostomy care, including changing the inner cannula. This procedure is within the nursing scope of practice and does not require a physician's intervention.

Choice B rationale:

Inserting a tunneled central venous catheter (such as a Hickman line) is a specialized procedure that generally falls under the scope of practice for advanced practice nurses (such as nurse practitioners or clinical nurse specialists) or physicians. RNs typically do not have the required training or authority to perform this invasive procedure.

Choice C rationale:

Irrigation of an external ear canal is within the legal scope of practice for registered nurses. Ear irrigation is a common nursing procedure used to remove impacted cerumen (earwax) and foreign bodies from the ear canal. Nurses are trained to perform this procedure safely and effectively.

Choice D rationale:

Administering blood products, including platelet transfusions, is within the legal scope of practice for an RN. RNs are responsible for preparing, verifying, and administering blood products according to institutional policies and procedures. This includes monitoring the patient during and after the transfusion for any adverse reactions.

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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?

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