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.

Answer and Explanation

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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Correct Answer is C

Explanation

- A. Incorrect. The client does not have respiratory alkalosis because respiratory alkalosis is characterized by a low PaCO2 (less than 35 mm Hg) and a high pH (greater than 7.45).

- B. Incorrect. The client does not have metabolic alkalosis because metabolic alkalosis is characterized by a high HCO3 (greater than 26 mEq/L) and a high pH (greater than 7.45).

- C. Correct. The client has respiratory acidosis because respiratory acidosis is characterized by a high PaCO2 (greater than 45 mm Hg) and a low pH (less than 7.35).

- D. Incorrect. The client does not have metabolic acidosis because metabolic acidosis is characterized by a low HCO3 (less than 22 mEq/L) and a low pH (less than 7.35).

A. Begin ball squeezing exercises. B. Wear a bra with wire support. C. Avoid using the affected arm for eating. D. Use deodorant under the affected arm.

Correct Answer is C

Explanation

Choice A rationale:

Beginning ball squeezing exercises is not advisable immediately after a modified radical mastectomy. The client's arm on the affected side needs time to heal, and strenuous exercises can strain the surgical site, increase pain, and potentially disrupt the healing process.

Choice B rationale:

Wearing a bra with wire support is not recommended, especially in the early postoperative period. Underwire bras can irritate the surgical site and interfere with the healing process. Patients are usually advised to wear soft, non-underwire bras or special post-surgical bras designed for comfort and support.

Choice C rationale:

Avoiding the use of the affected arm for eating is the correct instruction. Protecting the surgical site and preventing strain is essential for proper healing. Encouraging the client to use the opposite arm for activities like eating can minimize movement in the affected area, reducing the risk of complications.

Choice D rationale:

Using deodorant under the affected arm is not recommended immediately after surgery. The surgical site needs to be kept clean and dry to prevent infection and promote healing. Deodorants, especially those containing chemicals or fragrances, can irritate the skin and increase the risk of complications. Patients are usually advised to avoid applying any products to the surgical area until it is fully healed.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is reviewing the ABG values of a client. The client has a pH of 7.2, PaCO2 of 60 mm Hg, and HCO3 of 25 mEq/L. The nurse should identify that the client has which of the following acid-base imbalances?

Correct Answer is C

Explanation

A nurse is providing discharge teaching to a client who is 1 day postoperative following a right modified radical mastectomy.Which of the following instructions should the nurse include in the teaching?

Correct Answer is C

Explanation

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