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.

Answer and Explanation

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.

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Correct Answer is C

Explanation

Choice A reason: Removing the nasal cannula is not appropriate as it would deprive the client of supplemental oxygen. The client's oxygen saturation is below the normal range of 95% to 100%, indicating hypoxemia.

Choice B reason:While increasing oxygen might seem appropriate, this should only be done after verifying the accuracy of the pulse oximeter reading and assessing the client’s overall condition. Automatically increasing oxygen without further assessment could delay addressing other underlying issues or lead to over-oxygenation in clients with certain conditions like COPD.

Choice C reason:The first step is to ensure the accuracy of the pulse oximeter reading by checking its placement and ruling out factors that can interfere with accurate readings, such as poor circulation, cold extremities, nail polish, or motion artifacts. This ensures that the subsequent intervention is based on reliable data.

Choice D reason: Switching to a non-rebreather mask is not necessary as it would deliver a high concentration of oxygen (up to 100%) that may be excessive for the client. A nasal cannula can deliver oxygen from 1 to 6 L/minute, depending on the client's needs.

A. "Tell me about the visit with your significant other." B. "Would you like to talk for a little while?" C. "What did you enjoy about your visit tonight?" D. "I can see that you are feeling lonely." E. None F. None

Correct Answer is A

Explanation

Choice A reason: This is the most therapeutic response as it invites the client to share her feelings and thoughts about the visit. It also shows the nurse's interest and empathy for the client.

Choice B reason: This is a less therapeutic response as it is vague and non-specific. It does not address the client's behavior or mood. It also puts the burden on the client to initiate the conversation.

Choice C reason: This is a less therapeutic response as it assumes that the client enjoyed the visit. It may not reflect the client's true feelings or experiences. It also limits the client's expression to positive aspects only.

Choice D reason: This is a non-therapeutic response as it labels the client's emotion without validation. It may not accurately describe the client's feeling or situation. It also closes the communication by making a statement instead of asking a question.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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?

Correct Answer is C

Explanation

A female client assigned to a mental health unit visits with her significant other during the evening. After the significant other leaves, the nurse notices that the client is more isolative and refuses to attend the evening group. Which response by the nurse is most therapeutic?

Correct Answer is A

Explanation

The nurse observes that there are reddened areas on the cheekbones of a client receiving oxygen per nasal cannula at 3 L/minute, and the client's oxygen saturation level is 92%. Which intervention would the nurse implement?

The nurse is teaching a client about the use of syringes and needles for home administration of medications. Which action by the client indicates an understanding of standard precautions?

Which explanation is best for the nurse to provide a client who asks the purpose of using the log-rolling technique for turning?

A female client assigned to a mental health unit visits with her significant other during the evening. After the significant other leaves, the nurse notices that the client is more isolative and refuses to attend the evening group. Which response by the nurse is most therapeutic?

While interviewing a client, the nurse records the assessment in the electronic health record. Which statement is most accurate regarding electronic documentation during an interview?

A client's wife has just learned that her husband is terminally ill. She is sitting in the corner of the client's room crying, and says to the nurse, "I feel as if I'm already so alone." Which action should the nurse take first?

The nurse observes the unlicensed assistive personnel (UAP) securing a client's wrist restraints to the bedside rails. Which action is most important for the nurse to implement?