A nurse is providing teaching for a client who has a fracture of the right fibula with a shortleg cast in place and a new prescription for crutches. The client is non-weight-bearing for 6 weeks. Which of the following instructions should the nurse include in the teaching?
Adjust the crutches for comfort as needed.
Use a three-point gait.
Wear leather-soled shoes.
Advance the affected leg first when walking upstairs.
The Correct Answer is B
- A. Adjust the crutches for comfort as needed. This is incorrect because the crutches should be adjusted to fit the client's height and arm length, and should not be changed without proper guidance.
- B. Use a three-point gait. This is correct because this gait allows the client to avoid putting weight on the affected leg and maintain balance and stability.
- C. Wear leather-soled shoes. This is incorrect because leather-soled shoes can be slippery and increase the risk of falls and injuries.
- D. Advance the affected leg first when walking upstairs. This is incorrect because the client should advance the unaffected leg first when walking upstairs, and the affected leg first when walking downstairs.
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Related Questions
Correct Answer is D
Explanation
- A. Calories is incorrect. Clients with Crohn's disease and enteroenteric fistula need adequate calories to prevent malnutrition and weight loss due to inflammation, malabsorption, and increased metabolic rate.
- B. Protein is incorrect. Clients with Crohn's disease and enteroenteric fistula need adequate protein to promote tissue healing and prevent protein-losing enteropathy.
- C. Potassium is incorrect. Clients with Crohn's disease and enteroenteric fistula are at risk of hypokalemia due to diarrhea, vomiting, and fistula drainage. They need to increase their potassium intake to prevent electrolyte imbalance and cardiac complications.
- D. Fiber is correct. Clients with Crohn's disease and enteroenteric fistula should decrease their fiber intake to reduce intestinal motility, bulk, and gas production, which can worsen the inflammation and fistula formation.
Correct Answer is A
Explanation
- A is correct because delegating non-nursing tasks to ancillary staff allows nurses to focus on more complex and skilled tasks that require their expertise and judgment, thus improving efficiency and quality of care.
- B is incorrect because stocking client rooms with extra supplies increases waste and costs, as well as clutter and infection risk.
- C is incorrect because assigning dedicated equipment to each client's room reduces availability and accessibility of equipment for other clients, as well as increases maintenance and cleaning costs.
- D is incorrect because changing continuous IV infusion tubing every 24 hr is not cost-effective, as it does not reduce the risk of infection significantly compared to changing it every 72 hr, according to current evidence-based practice guidelines.
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