A nurse is reinforcing teaching about the use of crutches with a client who has a fractured right tibia and fibula. Which of the following statements by the client indicates an understanding of the teaching?
"I will be sure to keep the crutch tips dry."
"I will hold a crutch in each hand when sitting down."
"I will place my weight on my underarms."
"I will lead with my right leg when going upstairs."
The Correct Answer is A
A. Keeping the crutch tips dry is essential to prevent slipping and falling, which can lead to further injury. Moisture on the tips can reduce friction, making the crutches unstable on surfaces.
B. When sitting down, the correct technique involves holding both crutches in one hand and using the other hand to lower yourself safely into the chair. Holding a crutch in each hand can make it difficult to balance and sit down safely.
C. Placing weight on the underarms can cause nerve damage and pain. The correct technique is to place weight on the hands and use the muscles of the arms and shoulders to support the body.
D. When going upstairs with a fractured leg, the proper technique is to lead with the uninjured leg, not the injured one. This ensures stability and reduces the risk of further injury to the fractured leg.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A) Autonomy refers to the right of the client to make their own decisions about their care. In this scenario, the nurse respects the client's decision not to take the pill as it is, but does not stop there.
B) Beneficence is the principle of doing good and acting in the best interest of the client. By offering to break the pill, the nurse is actively seeking a solution to ensure the client receives the necessary medication, which is in the client's best interest.
C) Justice relates to fairness and the equal distribution of resources. While important, it is not the primary principle being demonstrated in this situation.
D) Nonmaleficence means to do no harm. Although breaking the pill could be seen as avoiding harm by preventing the client from choking, it is more about ensuring the client's treatment continues effectively, which aligns more closely with beneficence.
Correct Answer is D
Explanation
A. A urine specific gravity of 1.015 is within the normal range (1.005–1.030). While fluid volume excess may lead to a lower specific gravity due to urine dilution, this value does not indicate fluid overload and is considered normal.
B. A hematocrit level of 42% is within the normal range for adults (men: 38–50%, women: 35–45%). Hematocrit levels tend to decrease in fluid volume excess due to hemodilution, but this value does not suggest fluid overload.
C. A urine pH of 6.5 is within the normal range (4.5–8.0). Urine pH reflects the acid-base balance rather than fluid status and is not a reliable indicator of fluid volume excess.
D. A BUN level of 5 mg/dL is below the normal range (10–20 mg/dL). In fluid volume excess, the dilution of blood plasma can lead to decreased BUN levels. This low BUN value, in conjunction with clinical symptoms, supports the diagnosis of fluid volume excess.
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