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: 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.
Correct Answer is B
Explanation
Choice A reason: Applying lubricant to the cannula tubing is not the best intervention as it may cause irritation or infection of the nasal mucosa. The nurse should use water-soluble gel or saline spray to moisten the nasal passages if needed.
Choice B reason: Placing padding around the cannula tubing is the best intervention as it prevents friction and pressure on the skin. The nurse should use soft materials such as gauze or foam to cushion the tubing and check the skin integrity frequently.
Choice C reason: Decreasing the flow rate to 1 L/minute is not an appropriate intervention as it may compromise the client's oxygenation. The nurse should maintain the prescribed flow rate and monitor the client's vital signs and oxygen saturation.
Choice D reason: Discontinuing the use of the nasal cannula is not an option as it may endanger the client's life. The nurse should continue the oxygen therapy as ordered and provide comfort measures and education to the client.
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