A nurse is reinforcing teaching with a client who has an ankle injury and requires crutches. Which of the following instructions should the nurse provide?

"Maintain your head and neck erect when walking with crutches."

"Keep your elbows flexed at a 35° angle when using the crutches."

"Support your body weight by leaning on the crutches."

“Wash the tips of your crutches daily."

Answer and Explanation

The Correct Answer is B

A. "Maintain your head and neck erect when walking with crutches.": This is incorrect. The focus should be on posture and the use of crutches, not just the head and neck. Maintaining an erect posture is essential, but this option is too narrow and doesn’t provide full guidance on proper crutch use.

B. "Keep your elbows flexed at a 35° angle when using the crutches.": This is correct. The elbows should be slightly bent, approximately at a 30- to 35-degree angle, to ensure proper use of the crutches. This position prevents excessive strain on the shoulders and wrists while providing effective support.

C. "Support your body weight by leaning on the crutches.": This is incorrect. The crutches should not bear the entire weight of the body. Instead, the weight should be distributed through the arms and hands with the crutches supporting some of the load. Leaning on the crutches can lead to nerve damage or further injury.

D. “Wash the tips of your crutches daily.": This is incorrect. While it is important to keep crutches clean, washing the tips daily is unnecessary. It is more important to check the crutches for wear and tear and ensure the rubber tips are intact and provide proper traction.

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Correct Answer is C

Explanation

A. "Assign the task to another AP" is not the best first response. The nurse should first understand why the AP is refusing the task and address any concerns before reassigning the task.

B. "Report the AP to the risk manager" is premature. The nurse should first attempt to understand the AP’s reasons for refusal and resolve any concerns directly. Reporting should only occur if the issue persists and cannot be resolved.

C. "Discuss the AP's concerns about performing the task" is correct. The nurse should open a dialogue with the AP to understand why they are refusing the task. This allows the nurse to assess if the refusal is due to lack of knowledge, skill, or comfort, and then provide the necessary support, guidance, or training.

D. "Perform the task on behalf of the AP" is not ideal. The nurse should not assume the task but rather address the issue with the AP. The nurse should only intervene if the task needs to be completed urgently, but the first step should be to explore the reasons for refusal.

A. "We will frequently check the top of his ears for sores." B. "We can turn the oxygen up to 10 when he has trouble breathing." C. "We can use petroleum jelly to keep his nares moist." D. "We will need to remove the nasal cannula when he is eating."

Correct Answer is A

Explanation

A. Frequently checking the top of the ears for sores is correct. The nasal cannula tubing can cause pressure injuries behind the ears over time. The family should check for redness or sores and use protective padding or adjust the tubing as needed.

B. Turning the oxygen up to 10 when the client has trouble breathing is incorrect. Oxygen flow rates should be adjusted only as prescribed by the provider. Increasing the flow rate without guidance can lead to complications, such as oxygen toxicity in clients with chronic respiratory conditions.

C. Using petroleum jelly to keep the nares moist is incorrect. Petroleum-based products are flammable and should not be used with oxygen therapy. Instead, a water-based lubricant should be used to prevent nasal dryness.

D. Removing the nasal cannula when eating is incorrect. Clients using a nasal cannula can continue wearing it while eating, as it allows them to receive oxygen continuously. If needed, a healthcare provider can recommend adjustments to oxygen flow during meals.

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A nurse is reinforcing teaching with a client who has an ankle injury and requires crutches. Which of the following instructions should the nurse provide?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Explanation

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Correct Answer is A

Explanation

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