A nurse is teaching a client about crutch walking using the three-point gait. Which of the following statements by the nurse should be included in the teaching?

"Support your body weight on the underarm crutch pads."

"Look down at your feet before moving the crutches."

"Place one crutch forward with the opposite foot and then place the second crutch forward followed by the second foot."

"Move both crutches forward while standing on the unaffected leg, then lift and swing your body past the crutches."

Answer and Explanation

The Correct Answer is D

A.   Crutches should not be used to support body weight under the arms, as this can cause nerve damage or discomfort. Instead, weight should be supported on the hands and arms, with the crutches positioned to support the client’s weight. Proper use involves placing the crutches slightly in front of the feet, with weight supported on the hands, not the underarms.
B.   While it's important to be aware of your surroundings, looking down at your feet can be counterproductive as it may affect balance and coordination. The client should maintain an upright posture and look ahead to ensure proper gait and balance while moving. This helps in coordinating the movement of crutches and feet more effectively.
C.   In a four-point gait, each crutch and foot move alternately, which is different from the three-point gait. The three-point gait involves moving both crutches and the affected leg forward simultaneously, followed by the unaffected leg.
D.   In the three-point gait, the client moves both crutches forward at the same time while keeping the affected leg off the ground or in a non-weight-bearing position. Then, the client swings the unaffected leg forward to step past the crutches. This method ensures that weight is only placed on the unaffected leg while moving.

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Correct Answer is D

Explanation

A. Drinking adequate fluids is essential during pregnancy to support overall health and amniotic fluid levels. A general recommendation is to drink about 2 to 3 liters (8-12 cups) of fluids per day. This includes water, and sometimes other beverages and soups.
B. It is well-established that alcohol consumption during pregnancy is harmful and can lead to serious conditions such as fetal alcohol syndrome. The advice to avoid alcohol entirely during pregnancy is accurate and reflects current medical guidelines.
C. Moderate caffeine consumption is generally considered acceptable during pregnancy. Most guidelines suggest limiting caffeine intake to about 200-300 milligrams per day (equivalent to about 1-2 cups of coffee). This advice is consistent with current recommendations.
D. The recommended daily calcium intake during pregnancy is typically around 1,000 milligrams per day for most pregnant women. An intake of 1,500 milligrams per day is higher than the usual recommendation and may not be necessary unless specifically advised by a healthcare provider for individual circumstances.

A. The nurse allows the client to rest in a supine position during feeding. B. The nurse initiates the feeding after aspirating 50 mL of gastric residual. C. The nurse irrigates the NG tube with tap water after feeding. D. The nurse administers the feeding through a syringe barrel by gravity.

Correct Answer is A

Explanation

A. The supine position increases the risk of aspiration, where food or liquid could enter the airway and potentially cause aspiration pneumonia. To minimize this risk, the client should be positioned in a semi- Fowler’s position (head of the bed elevated at 30-45 degrees) during feedings.
B. Aspirating gastric residual volumes is a standard practice to check for proper digestion and tolerance of the feeding. Generally, a residual of up to 250-500 mL can be acceptable depending on institutional policy and client condition. This action does not necessarily require intervention unless specific guidelines indicate otherwise.
C. Irrigating the NG tube with tap water is a common practice to ensure the tube remains patent and to help clear any residual feeding material from the tube. Tap water is generally considered acceptable for this purpose, though some facilities may use sterile or distilled water to avoid any potential infections.
D. Administering the feeding through a syringe barrel by gravity is a standard method for intermittent tube feedings. This technique allows the feeding to flow slowly into the stomach without excessive pressure, which can help prevent complications such as nausea or cramping.

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A nurse is teaching a client about crutch walking using the three-point gait. Which of the following statements by the nurse should be included in the teaching?

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Naxlex Comprehensive Predictor Exams

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Correct Answer is D

Explanation

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Correct Answer is A

Explanation

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