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. Auscultate the bowel sounds in all four quadrants:

Auscultating bowel sounds is not directly relevant to nasopharyngeal suctioning. This assessment is more appropriate for evaluating gastrointestinal function and is not a priority during airway management procedures.

B. Palpate the client's pedal pulse volume bilaterally:

Palpating pedal pulse volume is not directly relevant to nasopharyngeal suctioning. This assessment is more appropriate for evaluating peripheral vascular perfusion and is not a priority during airway management procedures.

C. Determine the elasticity of the client's skin turgor:

Assessing skin turgor elasticity is not directly relevant to nasopharyngeal suctioning. This assessment is typically performed to evaluate hydration status and is not a priority during airway management procedures.

D. Observe the client's skin and mucous membranes:

This is the most appropriate assessment during nasopharyngeal suctioning. Observing the client's skin and mucous membranes helps monitor for signs of respiratory distress, such as cyanosis, pallor, or increased respiratory effort. It also allows the nurse to assess the effectiveness of airway clearance and potential complications related to the procedure.

A. 1.035. B. 1.015. C. 1.005. D. 1.025. E. 1.025.

Correct Answer is A

Explanation

A. 1.035:

This specific gravity value indicates highly concentrated urine. In the context of a client experiencing vomiting, diarrhea, and difficulty tolerating oral fluids, such a high specific gravity would be indicative of significant dehydration. Dehydration occurs when the body loses more fluid than it takes in, leading to an imbalance in electrolytes and an increase in urine concentration.

B. 1.015:

This specific gravity value falls within the normal reference range for urine specific gravity. In the context of vomiting, diarrhea, and difficulty tolerating oral fluids, a value within the normal range may be less likely. However, it's important to note that initial testing may not reflect the full extent of dehydration, especially if the client's fluid intake has been severely limited over a short period.

C. 1.005:

This specific gravity value is at the lower end of the normal reference range for urine specific gravity. In a client experiencing significant fluid loss through vomiting and diarrhea, the urine may become more concentrated as the body attempts to conserve water. Therefore, a value of 1.005 would be less likely on initial testing in this context.

D. 1.025:

Similar to Option B, this specific gravity value falls within the normal reference range. While it's possible for a dehydrated individual to have a specific gravity within the normal range, a value of 1.025 may be less likely in the context of significant fluid loss through vomiting and diarrhea. However, it's important to consider that dehydration severity and urine concentration can vary among individuals.

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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

Which client assessment should the nurse perform during nasopharyngeal suctioning?

Correct Answer is D

Explanation

The nurse is assessing a client who reports a 3 day history of vomiting and diarrhea and experiencing difficulty in tolerating oral fluids. Which urine specific gravity value would the nurse expect to see on Initial testing? Reference Range: Urine Specific Gravity [1.005 to 1.03]

Correct Answer is A

Explanation

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