A client with a sprained ankle is seen at the clinic and is given a pair of crutches. When the client stands with the aid of the crutches, the nurse notes a space of three finger widths between the top of the crutch and the client's axilla. Which action should the nurse take?

Confer with the physical therapist for correct crutch size.

Ask the client to sit down while the crutch length is adjusted.

Assess the client for signs of diminished circulation in the hands.

Proceed with teaching the client how to walk with the crutches.

Answer and Explanation

The Correct Answer is D

The correct answer is choice d. Proceed with teaching the client how to walk with the crutches.

Choice A rationale:

Confer with the physical therapist for correct crutch size. This is unnecessary because the crutches are already correctly fitted. A space of three finger widths between the top of the crutch and the client’s axilla is appropriate to prevent pressure on the axilla and potential nerve damage.

Choice B rationale:

Ask the client to sit down while the crutch length is adjusted. This action is not needed since the crutches are already properly adjusted. Adjusting the crutch length further could lead to improper fitting, which might cause discomfort or injury.

Choice C rationale:

Assess the client for signs of diminished circulation in the hands. While assessing circulation is important, it is not directly related to the fitting of the crutches. Proper crutch fitting focuses on ensuring there is no pressure on the axilla and that the client can use the crutches comfortably.

Choice D rationale:

Proceed with teaching the client how to walk with the crutches. This is the correct action because the crutches are already properly fitted. The nurse should now focus on educating the client on the correct use of the crutches to ensure safe and effective mobility.

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Correct Answer is ["2"]

Explanation

The healthcare provider has prescribed 4,800 mg of magnesium hydroxide. The bottle indicates that each 5 mL contains 400 mg of magnesium hydroxide. We also know that 1 ounce (oz) is equivalent to 30 mL.

Step 1: The amount of magnesium hydroxide the patient needs is 4,800 mg.

Step 2: The concentration of the magnesium hydroxide solution is 400 mg per 5 mL. Step 3: Substitute the values into the formula: 4,800 mg ÷ (400 mg/5 mL).

Step 4: Calculate the volume in mL: 4,800 ÷ (400/5) = 60 mL.

Now, we need to convert this volume from mL to ounces.

Step 5: We know that 1 oz = 30 mL.

Step 6: Substitute the values into the formula: 60 mL ÷ 30 mL/oz.

Step 7: Calculate the volume in oz: 60 ÷ 30 = 2 oz.

A. Give the patient 8 ounces (240 mL) of water to drink. B. Notify the healthcare provider. C. Check the drainage tubing for a kink. D. Review the intake and output record.

Correct Answer is C

Explanation

Choice A reason: Giving water may be necessary, but it is not the first intervention if there is a concern about urinary output.

Choice B reason: Notifying the healthcare provider is important but should occur after initial assessments and interventions.

Choice C reason: Checking for a kink in the drainage tubing is a quick and simple intervention that may resolve the issue of low output.

Choice D reason: Reviewing the intake and output record is important for understanding the patient's fluid status but is not the first action to take in this situation.

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A client with a sprained ankle is seen at the clinic and is given a pair of crutches. When the client stands with the aid of the crutches, the nurse notes a space of three finger widths between the top of the crutch and the client's axilla. Which action should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is ["2"]

Explanation

The nurse receives a report that a patient with an indwelling urinary catheter has an output of 150 mL for the previous 8-hour shift. Which intervention should the nurse implement first?

Correct Answer is C

Explanation

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