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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 ["C","E"]

Explanation

A. Placenta previa: The client's symptoms do not specifically suggest placenta previa, which is characterized by painless vaginal bleeding, not back pain.
B. Disseminated intravascular coagulation: The client's symptoms and vital signs do not suggest disseminated intravascular coagulation, which is a serious condition characterized by excessive bleeding and clotting throughout the body.
C. Preeclampsia: The presence of uterine contractions, elevated blood pressure, and a potential increase in body temperature can indicate the risk of developing preeclampsia, a condition characterized by high blood pressure and signs of damage to other organ systems, often developing after the 20th week of pregnancy.
D. Sepsis: While the client has an elevated temperature, the symptoms provided do not strongly indicate sepsis. Other signs, such as rapid heart rate, low blood pressure, and changes in mental status, are usually associated with sepsis.
E. Preterm prelabour rupture of membranes (PROM): The client's report of lower back pain, pinkish vaginal discharge, and uterine contractions can raise concern for the risk of preterm prelabour rupture of membranes, where the amniotic sac ruptures before the onset of labor.
F. Seizures: The client's symptoms and information provided do not indicate a risk of seizures. Seizures can be associated with conditions like preeclampsia but are not directly indicated by the client's current assessment.

A. The nurse should use a filter needle to withdraw the medication. B. The nurse should use the same needle to draw up and inject the client. C. The nurse should break the neck of the ampule toward their body. D. The nurse should dispose of the ampule in the trash can.

Correct Answer is A

Explanation

A. Correct. A filter needle should be used to withdraw medication from an ampule to prevent drawing up any glass fragments into the syringe.
B. Using the same needle to draw up and inject the client is not recommended to prevent contamination.
C. Breaking the neck of the ampule toward the body is not a safe practice, as it can cause injury.
D. Ampules should be disposed of properly in a sharps container, not a regular trash can.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is ["C","E"]

Explanation

A nurse is preparing to administer a medication that is available in a glass ampule. Which of the following actions should the nurse plan to take?

Correct Answer is A

Explanation

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