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 ["A","C","E"]

Explanation

Choice A reason: Orienting the client to their surroundings is essential for a confused patient. It can help reduce anxiety and prevent further confusion. It is a non-invasive, immediate intervention that can provide comfort and safety to the patient.

Choice B reason: Closing the client's room door is not recommended as it may increase the patient's feeling of isolation and can be a safety issue if the patient needs immediate assistance.

Choice C reason: Escorting the client back to the room is a correct action. It ensures the safety of the client by preventing falls or wandering, which could lead to harm.

Choice D reason: Raising all four side rails on the bed can be considered a form of restraint and is not recommended. It can increase the risk of injury if the client attempts to climb over the rails and can contribute to feelings of confusion and agitation.

Choice E reason: Securing a bed alarm on the mattress is a correct action. It alerts the staff if the client attempts to leave the bed, allowing for quick intervention to ensure the client's safety.

A. Medication reference guide. B. Nursing unit charge nurse. C. Healthcare provider. D. Hospital pharmacist.

Correct Answer is C

Explanation

Choice A reason: While a medication reference guide is useful, it does not replace the need for clarification from the prescribing healthcare provider regarding dosage discrepancies.

Choice B reason: The nursing unit charge nurse can be a resource, but the prescriber should be the first contact for medication orders.

Choice C reason: The healthcare provider who prescribed the medication is the most appropriate resource to clarify and potentially correct the dosage of the oral antibiotic.

Choice D reason: The hospital pharmacist is a valuable resource for medication information and can be consulted, but the prescriber should first be contacted to address the discrepancy in dosages.

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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

A nurse finds a confused client wandering in the hallway during the night. What actions should the nurse implement? Select all that apply.

Correct Answer is ["A","C","E"]

Explanation

Correct Answer is C

Explanation

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