The nurse is demonstrating three point gait crutch walking to an older adult client who broke a foot while playing soccer with the grandchildren. Which behavior Indicates that the client understands proper crutch walking?

Progresses to foot touchdown and weight bearing of affected leg.

Practices bicep and triceps isometric exercises.

Inspects crutches to ensure rubber tips are intact.

Bears body weight on the palms of hands during the crutch gait.

Answer and Explanation

The Correct Answer is A

A. Progresses to foot touchdown and weight bearing of affected leg:

This choice indicates that the client understands proper crutch walking because it involves the correct progression of weight-bearing on the affected leg while using the crutches for support. In the three-point gait crutch walking technique, the client progresses by first touching down the foot of the affected leg and then transferring weight onto that leg while stepping forward with the crutches. This behavior ensures proper balance and support during ambulation.

B. Practices bicep and triceps isometric exercises:

This choice does not directly indicate understanding of proper crutch walking. While strengthening the biceps and triceps muscles can be beneficial for overall strength and endurance, it is not a specific behavior related to proper crutch walking technique.

C. Inspects crutches to ensure rubber tips are intact:

While it is important to inspect crutches regularly to ensure they are in good condition, this behavior alone does not necessarily indicate an understanding of proper crutch walking technique. It is more related to equipment maintenance and safety rather than the actual execution of crutch walking.

D. Bears body weight on the palms of hands during the crutch gait:

This choice suggests an incorrect technique. Proper crutch walking technique involves bearing weight on the hands through the hand grips of the crutches rather than the palms. Placing excessive weight on the palms can lead to discomfort, injury, and improper weight distribution, which could hinder effective ambulation.

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Correct Answer is D

Explanation

A. Clamping the urinary catheter prior to the collection:

This step involves temporarily stopping the flow of urine through the catheter. Whether gloves are needed for this step depends on the specific protocol and the potential risk of exposure to bodily fluids. If there's a possibility of urine leakage or splashing during the clamping process, gloves may be necessary to protect against contact with the urine.

B. Recording the output on the flowsheet in the client's room:

This step involves documenting the urine output on a flowsheet or chart. It typically does not require direct contact with bodily fluids, as the nurse is handling paperwork rather than the urine itself. Therefore, gloves are usually not necessary for this task.

C. Transporting the urine specimen to the laboratory:

Once the urine specimen has been collected and properly sealed in a biohazard bag, the nurse transports it to the laboratory for analysis. As long as the specimen is securely packaged, there is no need for gloves during transportation unless there is a risk of spillage or leakage. However, if there is a possibility of contact with bodily fluids due to leakage, gloves should be worn to protect against exposure.

D. Using the syringe to remove the specimen from the catheter:

This step involves using a sterile syringe to withdraw the urine from the catheter for collection. Since it involves direct contact with bodily fluids (i.e., urine), gloves are necessary to protect against potential exposure to pathogens. Wearing gloves during this step helps maintain proper infection control practices and minimizes the risk of contamination.

A. Capillary refill of 2 seconds in the lower right foot. B. Basilar lung sounds that are diminished in the left lung. C. Contraction of the left pupil when light shines in the right eye. D. Active bowel sounds in the lower right quadrant.

Correct Answer is B

Explanation

A. Capillary refill of 2 seconds in the lower right foot:

Capillary refill of 2 seconds in the lower right foot is within normal limits and does not require documentation in a chart-by-exception system, as it is considered an expected finding.

B. Basilar lung sounds that are diminished in the left lung:

Diminished basilar lung sounds in the left lung may indicate a respiratory issue and would be considered a significant finding warranting documentation in a chart-by-exception system.

C. Contraction of the left pupil when light shines in the right eye:

Contraction of the left pupil when light shines in the right eye is an abnormal finding (consensual response), which should be documented in a chart-by-exception system.

D. Active bowel sounds in the lower right quadrant:

Active bowel sounds in the lower right quadrant are within normal limits and do not require documentation in a chart-by-exception system, as they are considered expected findings.

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The nurse is demonstrating three point gait crutch walking to an older adult client who broke a foot while playing soccer with the grandchildren. Which behavior Indicates that the client understands proper crutch walking?

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Naxlex Comprehensive Predictor Exams

The nurse uses a sterile syringe to obtain a urine specimen from a client's indwelling urinary catheter. After placing the specimen in a biohazard bag, the nurse transports the specimen to the laboratory. During which part of this procedure should the nurse wear gloves?

Correct Answer is D

Explanation

A healthcare organization requires nurses to chart by exception. Which assessment should the nurse document?

Correct Answer is B

Explanation

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The nurse is demonstrating three point gait crutch walking to an older adult client who broke a foot while playing soccer with the grandchildren. Which behavior Indicates that the client understands proper crutch walking?

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The nurse is caring for a client who is postoperative and receiving supplemental oxygen at 2 L/minute via nasal cannula. The oxygen saturation is 89%. Which action should the nurse implement?