A nurse is assisting a client who has received crutches in an urgent care center following a foot injury. Which of the following statements should the nurse identify as an indication that the client needs additional teaching?

“I will bear the weight of my body on my hands.”

"I have a set of my brother's old crutches in my basement I can also use."

“I will keep spare crutch tips handy.”

“I will inspect my crutches every day for signs of wear.”

Answer and Explanation

Correct Answer : A,B

Choice A rationale: Bearing the weight of the body on the hands is not the correct technique for using crutches. The weight should be borne on the arms, not the hands.
Choice B rationale: Using crutches that belonged to someone else may not be appropriate as they need to be properly fitted for the individual. Additionally, old crutches may be worn or damaged.
Choice C rationale: This statement is appropriate and does not indicate a need for additional teaching. Keeping spare crutch tips is a good practice, as crutch tips can wear down over time and may need replacement. This demonstrates the client's understanding of the need for maintenance and preparedness.
Choice D rationale: This statement is appropriate and indicates a good understanding of crutch care. Regular inspection of crutches is important to ensure their safety and effectiveness. It allows the client to identify any signs of wear or damage early on and take necessary actions, such as replacing worn-out parts, to prevent accidents or injuries.

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Correct Answer is B

Explanation

Choice A rationale: Decubitus ulcers (pressure ulcers) are not directly prevented by applying padded boots for dorsiflexion.
Choice B rationale: Applying padded boots for dorsiflexion helps prevent foot drop, a condition where the foot is permanently in a plantar-flexed position, which can lead to contractures.
Choice C rationale: Pooling of blood is not a primary concern addressed by applying padded boots for dorsiflexion.
Choice D rationale: Blood pressure changes are not directly addressed by applying padded boots for dorsiflexion.

A. Perform hand hygiene. B. Assess the condition of the visible wound bed. C. Measure the width of the wound with a disposable ruler. D. Insert a swab into the wound at 90 degrees.

Correct Answer is A

Explanation

Choice A rationale: Performing hand hygiene before any wound care procedure is essential to prevent infection and maintain aseptic technique.
Choice B rationale: Assessing the condition of the visible wound bed is an important step but not the first action. Hand hygiene should precede any assessment or intervention.
Choice C rationale: Measuring the width of the wound with a disposable ruler is part of the wound measurement process but should follow hand hygiene.
Choice D rationale: Inserting a swab into the wound at 90 degrees is not the first step. Hand hygiene and assessment should precede any invasive procedures.

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A nurse is assisting a client who has received crutches in an urgent care center following a foot injury. Which of the following statements should the nurse identify as an indication that the client needs additional teaching?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse applies padded boots to maintain the foot in dorsiflexion to a client who is comatose. The nurse is protecting the client from:

Correct Answer is B

Explanation

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Correct Answer is A

Explanation

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