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.

Answer and Explanation

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 not correct because in a three-point gait, the two crutches and the affected leg move together, followed by the stronger leg.

Choice B rationale:

Supporting body weight while leaning on the axillary crutch pads is incorrect as this can cause nerve damage under the arms. Weight should be supported by the hands while using crutches.

Choice C rationale:

Stepping with the affected leg first when going up stairs is incorrect. When ascending stairs, the unaffected (stronger) leg should be moved first, followed by the affected leg and crutches.

Choice D rationale:

Positioning both hands on the grips with elbows slightly flexed is correct as it allows for proper weight distribution through the arms and hands, which is essential for balance and safety while using crutches.

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Correct Answer is A

Explanation

A client who is ambulatory and receiving oxygen should be evacuated first during a fire because they are at risk of fire and explosion from the oxygen source. The nurse should instruct the staff to turn off the oxygen supply, remove the oxygen device from the client, and assist them to walk out of the building using the nearest exit.
Choice B is wrong because a client who uses a wheelchair and is confused is not in immediate danger from the fire. They can be evacuated using a swing carry or an extremity carry by two staff members after the clients who are more vulnerable are evacuated.
Choice C is wrong because a client who is bedridden and wears a hearing aid is not in immediate danger from the fire. They can be evacuated using a cradle drop by one staff member after the clients who are more vulnerable are evacuated.
Choice D is wrong because a client who has a fracture and is in balance suspension traction is not in immediate danger from the fire. They can be evacuated using a special device such as a sked or a sled by two or more staff members after the clients who are more vulnerable are evacuated.

A. Observe the position of the suspended weight. B. Check the client’s pedal pulse on the right leg. C. Ask the client to describe her pain. D. Remind the client to use the incentive spirometer.

Correct Answer is D

Explanation

The correct answer is choiceD. Remind the client to use the incentive spirometer.

Choice A rationale:

Observing the position of the suspended weight requires clinical judgment to ensure proper alignment and effectiveness of the traction, which is beyond the scope of practice for assistive personnel.

Choice B rationale:

Checking the client’s pedal pulse on the right leg involves assessing circulation, which is a clinical task that should be performed by a licensed nurse.

Choice C rationale:

Asking the client to describe her pain involves pain assessment, which requires clinical judgment and should be done by a nurse.

Choice D rationale:

Reminding the client to use the incentive spirometer is a task that can be delegated to assistive personnel as it involves reinforcing previously taught instructions without requiring clinical judgment.

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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

A nurse is providing an in-service about client evacuation during a fire. Which of the following clients should the nurse instruct the staff to evacuate first?

Correct Answer is A

Explanation

A nurse is developing a care plan for a client who is in Buck’s traction and is scheduled for surgery for a fractured femur of the right leg. Which of the following interventions should the nurse delegate to an assistive personnel?

Correct Answer is D

Explanation

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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?