A nurse is reinforcing teaching with a client about the use of crutches. Which of the following actions by the client indicates an understanding of the teaching?
The client leans on the crutches for support while standing still.
The client advances the unaffected leg first while climbing stairs.
The client stands 5 cm (2 in) from the front of a chair before sitting.
The client bears weight on their axilla while standing in the tripod position.
The Correct Answer is B
A: Incorrect. Leaning on the crutches for support while standing still is not the correct way to use crutches. It can lead to discomfort and instability.
B: Correct. The client should advance the unaffected leg first while climbing stairs when using crutches. This technique ensures better stability and safety during stair ascent.
C: Incorrect. Standing 5 cm (2 in) from the front of a chair before sitting is not directly related to the use of crutches.
D: Incorrect. Bearing weight on the axilla while standing in the tripod position is not the correct way to use crutches. The tripod position is used for resting, not weight bearing.
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Naxlex Comprehensive Predictor Exams
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Correct Answer is {"dropdown-group-1":"C","dropdown-group-2":"E"}
Explanation
The nurse should first review the medications that may be causing the client's confusion, as certain drugs can contribute to altered mental status and should be promptly identified and addressed. After identifying and managing the cause, the nurse should focus on using alternative methods to keep the client safe, ensuring both immediate and long-term patient safety, especially if medication adjustments are required.
Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"A"}
Explanation
Allergic reaction: The client is at risk of blood transfusion reaction as evidenced by an increase in respiratory rate to 22 and the increase in heart rate from 88 to 100.
Itching: itching is an immediate symptom of type 1 hypersensitivity reaction that are common with blood transfusion.
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