A nurse is assessing a client's ability to ambulate with crutches using a three-point gait. Which of the following actions should the nurse identify as a risk to the client's safety?

The client stands in a tripod position prior to walking.

The client keeps the elbows in a flexed position.

The client pushes downward on the handgrips.

The client places partial weight on the affected leg.

Answer and Explanation

The Correct Answer is D

A. Standing in a tripod position prior to walking with crutches is a correct stance to maintain balance and stability.
B. Keeping the elbows flexed helps absorb shock during ambulation and is appropriate when using crutches.
C. Pushing downward on the handgrips is necessary to generate upward force and support while using crutches.
D. Placing partial weight on the affected leg while ambulating with crutches using a three-point gait is incorrect and can jeopardize safety by potentially causing injury or instability.

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Correct Answer is C

Explanation

A. A blood glucose reading of 70 mg/dL is low but stable, and the client has already received treatment.
B. Pulling out a peripheral IV catheter is concerning but not immediately life-threatening.
C. New onset of indigestion in a client admitted for chest pain could indicate a cardiac event and requires immediate assessment.
D. A temperature of 38.9°C (102°F) in a client with pneumonia needs monitoring but is not as urgent as potential cardiac issues.

A. Check the client's motor strength. B. Loosen the clothing around the client's waist. C. Turn the client's head to the side. D. Document the time the seizure began.

Correct Answer is C

Explanation

A. Checking the client's motor strength is important after the seizure has ended to assess for any postictal weakness.
B. Loosening clothing can be done after ensuring the client's safety during the seizure.
C. Turning the client's head to the side helps prevent aspiration and ensures a clear airway during the seizure.
D. Documenting the time the seizure began is important for accurate medical record-keeping but is not the first action during an active seizure.

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A nurse is assessing a client's ability to ambulate with crutches using a three-point gait. Which of the following actions should the nurse identify as a risk to the client's safety?

Nursing Test Bank

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