A nurse is reinforcing teaching with a client about the use of crutches. Which of the following actions by the client indicates an understanding of the teaching?
The client leans on the crutches for support while standing still.
The client advances the unaffected leg first while climbing stairs.
The client stands 5 cm (2 in) from the front of a chair before sitting.
The client bears weight on their axilla while standing in the tripod position.
The Correct Answer is B
A: Incorrect. Leaning on the crutches for support while standing still is not the correct way to use crutches. It can lead to discomfort and instability.
B: Correct. The client should advance the unaffected leg first while climbing stairs when using crutches. This technique ensures better stability and safety during stair ascent.
C: Incorrect. Standing 5 cm (2 in) from the front of a chair before sitting is not directly related to the use of crutches.
D: Incorrect. Bearing weight on the axilla while standing in the tripod position is not the correct way to use crutches. The tripod position is used for resting, not weight bearing.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Place the client's medication record on the bedside table while ambulating the client: This action does not relate to protecting the client's privacy. It might actually compromise confidentiality by leaving sensitive information exposed.
B. Give a report about the client's status while standing at the nurses' station: This action does not protect the client's privacy. Discussing sensitive information in a public area can lead to breaches of confidentiality.
C. Speak with the client about their condition after visitors have left: Correct. Protecting the client's privacy is essential, and discussing personal health information in private with the client respects their right to confidentiality.
D. Place a message board in the client's room to post dietary information: This action does not relate to protecting the client's privacy. Posting dietary information may be helpful for staff, but it doesn't address the client's privacy concerns.
Correct Answer is ["C","D","F"]
Explanation
A: The neurological findings were already noted in the nurse's initial assessment, and the client's orientation and movement of extremities are within the expected range postoperatively.
Therefore, it does not require immediate reporting.
B: While the initial assessment indicated drainage on the dressing, there has been no further drainage since that time. A small amount of drainage following abdominal surgery is an expected finding and does not need to be reported to the provider unless drainage continues or increases over time.
C: Monitoring urinary output is essential, especially in a postoperative client, as it helps assess renal function and hydration status. Any significant changes in urinary output should be reported to the provider promptly.
D: The client's reported pain level of 6 on a scale of 0 to 10 indicates moderate pain, and the provider should be informed to address the pain and consider adjustments to the pain management plan.
E.Gastrointestinal assessment is incorrect. While nausea and hypoactive bowel sounds were initially noted, the client reports relief after the administration of metoclopramide.
F.Vital signs is correct. The client's heart rate and respiratory rate have increased, and their blood pressure and oxygen saturation levels have decreased. These findings should be reported to the provider.
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