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A nurse is providing teaching about the use of crutches using a three-point gait to a client who has a tibia fracture.

Which of the following actions by the client indicates an understanding of the teaching?

Moving both crutches with the stronger leg forward first.

Supporting his body weight while leaning on the axillary crutch pads

Stepping with his affected leg first when going up stairs

Positioning both hands on the grips with his elbows slightly flexed.

Answer and Explanation

The Correct Answer is D

The correct answer is Choice d. Positioning both hands on the grips with his elbows slightly flexed.

Choice A rationale:

Moving both crutches with the stronger leg forward first is incorrect for a three-point gait. This describes a two-point gait, which is used when a client can bear weight on both legs. In a three-point gait, the client bears weight on the unaffected leg and the crutches, not the stronger leg.
This action would put excessive weight on the affected leg and could potentially compromise healing or cause further injury.

Choice B rationale:

Supporting his body weight while leaning on the axillary crutch pads is also incorrect. This can lead to nerve damage in the armpits and should be avoided.
The weight should be distributed through the hands and wrists, not the armpits.

Choice C rationale:

Stepping with his affected leg first when going up stairs is incorrect and potentially dangerous. The client should lead with the stronger leg when going up stairs to maintain balance and control.

Choice D rationale:

Positioning both hands on the grips with his elbows slightly flexed is the correct action for using crutches with a three-point gait. This allows for proper weight distribution, balance, and control of the crutches.
It also helps to prevent fatigue and strain in the arms and shoulders.

Key points to remember about the three-point gait:

Weight is borne on the unaffected leg and the crutches, not the affected leg.
The crutches and the unaffected leg move forward together, followed by the affected leg.
The client should look ahead, not down at their feet.
The client should take small, even steps.
The client should rest as needed.

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Correct Answer is C

Explanation

The correct answer is choiceC. Remove the cap and place it sterile-side up on a clean surface.

Choice A rationale:

Placing sterile gauze over areas of spilled solution within the sterile field is not recommended. Spilled solution can compromise the sterility of the field, and covering it with gauze does not restore sterility. Instead, the nurse should avoid spilling solution to maintain the sterile field.

Choice B rationale:

Holding the irrigation solution bottle with the label facing away from the palm of the hand is incorrect. The correct technique is to hold the bottle with the label facing the palm. This prevents the label from getting wet and unreadable, ensuring that the nurse can always identify the solution correctly.

Choice C rationale:

Removing the cap and placing it sterile-side up on a clean surface is the correct action. This maintains the sterility of the cap, preventing contamination when it is replaced on the bottle. Ensuring the cap remains sterile is crucial for maintaining the sterility of the solution.

Choice D rationale:

Holding the bottle in the center of the sterile field when pouring the solution is incorrect. The bottle should be held outside the sterile field to prevent contamination. The solution should be poured carefully to avoid splashing and compromising the sterile field.

A. Administer epinephrine subcutaneously. B. Place the blood bag in a biohazard bag before discarding. C. Document the reaction in the medical record. D. Infuse 500 ml lactated Ringer's IV.

Correct Answer is C

Explanation

Choice A reason:

Administer epinephrine subcutaneously. This is not the necessary action to be taken. Epinephrine is used to treat severe allergic reactions (anaphylaxis). However, in this case, the client is experiencing a febrile non-haemolytic transfusion reaction, not an allergic reaction.

Choice B reason:

Place the blood bag in a biohazard bag before discarding. This is not the necessary action to be taken by the nurse. Proper disposal of biohazardous materials is essential, but in this situation, the nurse's priority is to address the client's condition and not the disposal of the blood bag

Choice C reason:

Documentation of the transfusion reaction is crucial for the client's medical history and for future reference. The nurse should record the client's signs and symptoms, the actions taken, and any other relevant information related to the reaction.

Choice D reason

Infuse 500 ml lactated Ringer's IV. This is not necessary action to be taken by the nurse because there is no indication for infusing lactated Ringer's solution in response to the transfusion reaction described. Treatment for febrile non-haemolytic transfusion reactions generally involves stopping the transfusion, administering antipyretics (like acetaminophen) if necessary, and providing supportive care as needed.

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A nurse is providing teaching about the use of crutches using a three-point gait to a client who has a tibia fracture. Which of the following actions by the client indicates an understanding of the teaching?

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A nurse is setting up a sterile field to perform wound irrigation for a client. Which of the following actions should the nurse take when pouring the sterile solution?

Correct Answer is C

Explanation

Choice A rationale:

Choice B rationale:

Choice C rationale:

Choice D rationale:

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Correct Answer is C

Explanation

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A nurse is providing teaching about the use of crutches using a three-point gait to a client who has a tibia fracture.

Which of the following actions by the client indicates an understanding of the teaching?