The nurse is teaching a client about how to use crutches. Which action performed by the client demonstrates to the nurse a correct understanding of how to use the crutches?
Walks with the arms fully extended.
Fits the crutch 2 finger widths from axilla.
Avoids adjusting the height of the hand grips.
Holds the crutch 6 inches (15 cm) to the side.
The Correct Answer is B
Choice A reason: This is an incorrect action as it indicates poor posture and balance. The client should walk with the elbows slightly flexed and the shoulders relaxed.
Choice B reason: This is the correct action as it ensures proper fit and comfort of the crutch. The client should fit the crutch 2 finger widths from the axilla to prevent nerve damage and pressure ulcers.
Choice C reason: This is an incorrect action as it may cause pain and injury to the wrists and hands. The client should adjust the height of the hand grips to allow a 30-degree bend at the elbow.
Choice D reason: This is an incorrect action as it may cause instability and falls. The client should hold the crutch 4 to 6 inches (10 to 15 cm) in front and to the side of the foot.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A reason: Printing electronic medical record (EMR) from backup server is not the best action to take first. It may not be possible or feasible to access the backup server if the system is down. It may also delay the communication and delivery of the prescriptions to the lab.
Choice B reason: Notifying information services department of the situation is the best action to take first. It alerts the experts who can troubleshoot and fix the problem as soon as possible. It also allows the nurse to obtain guidance on how to proceed with the documentation and prescriptions.
Choice C reason: Identifying information as late entry in the record is a relevant action to take, but not the first one. It ensures the accuracy and completeness of the EMR, but it does not address the immediate issue of the system failure. The nurse may not be able to enter the information until the system is restored.
Choice D reason: Waiting for notification that the system has been rebooted is not a proactive action to take first. It may waste valuable time and compromise the client's care. The nurse should not assume that the system will be rebooted automatically or quickly.
Correct Answer is B
Explanation
Choice A reason: Serum potassium and sodium levels are not relevant to the assessment of the wound infection. They are electrolytes that regulate fluid balance, nerve conduction, and muscle contraction. They may be affected by dehydration, renal failure, or diuretics.
Choice B reason: Neutrophil count is the most relevant laboratory value to note before reporting the wound infection. Neutrophils are white blood cells that fight bacterial infections and inflammation. A high neutrophil count indicates an acute infection or inflammation, while a low neutrophil count indicates a compromised immune system or a chronic infection.
Choice C reason: Blood pH level is not relevant to the assessment of the wound infection. It is a measure of the acidity or alkalinity of the blood. It may be affected by respiratory or metabolic disorders, such as acidosis or alkalosis.
Choice D reason: Hematocrit is not relevant to the assessment of the wound infection. It is the percentage of red blood cells in the blood. It may be affected by anemia, dehydration, or polycythemia.
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