A nurse is assessing internal variables that are affecting the patient's health status. Which area should the nurse assess?

A) The nurse opens the top flap of a sterile tray toward the body when assisting the provider with a thoracentesis: This is incorrect technique. The sterile field should always be maintained, and when opening sterile trays, the nurse should open the flap away from the body to avoid contaminating the sterile field. Opening the flap toward the body increases the risk of contamination and compromises sterility, which is critical in maintaining aseptic technique during procedures.

B) The nurse uses clean gloves when discontinuing a client's intravenous infusion: Using clean gloves when discontinuing an intravenous infusion is appropriate. Clean gloves are sufficient for this non-sterile task, as the procedure does not involve direct contact with sterile body tissues or fluids. Sterile gloves are not necessary unless the task requires maintaining sterility, such as inserting a catheter.

C) The nurse uses the client's telephone number as one form of identification when administering medications to a client: This is a correct action, as the nurse is verifying the patient's identity before administering medication. It is important to use at least two identifiers (such as the patient's name and date of birth or medical record number) to ensure accurate identification, and the patient's telephone number can be an additional form of identification.

D) The nurse empties the client's drainable colostomy pouch when it is one third full: This is an appropriate action. The nurse should empty the colostomy pouch when it is one third to one half full to prevent leakage or discomfort. This action is part of proper colostomy care and helps maintain hygiene and comfort for the patient.

A) The client pushes downward on the handgrips: Pushing downward on the handgrips of the crutches helps the client maintain balance and support, which is crucial for safely using crutches. This action aids in transferring weight and can provide stability during movement. As long as the client does not push too forcefully, this action is appropriate and not a safety risk.

B) The client stands in a tripod position prior to walking: The tripod position is a standard stance for crutch walking, where the crutches are placed slightly ahead and wider than the feet to provide a stable base of support. This position helps prevent the client from losing balance before starting to walk and is essential for maintaining safety while ambulating.

C) The client places partial weight on the affected leg: In a three-point gait, placing partial weight on the affected leg is a proper and necessary action to maintain the correct gait. This allows for proper distribution of weight between the crutches and the unaffected leg. The partial weight-bearing is often part of the rehabilitation process for clients with an injured or weakened leg.

D) The client keeps the elbows in a fixed position: Keeping the elbows in a fixed position during crutch walking can be dangerous, as it limits the client’s ability to adjust their posture or support properly. Flexing the elbows to about 20 to 30 degrees is ideal for balance, shock absorption, and mobility. A fixed elbow position restricts these movements, making it a safety concern because it could lead to muscle strain or decreased control over crutch placement.