A nurse is reinforcing teaching with a client who has an ankle injury and requires crutches. Which of the following instructions should the nurse provide?

"Maintain your head and neck erect when walking with crutches."

"Keep your elbows flexed at a 35° angle when using the crutches."

"Support your body weight by leaning on the crutches."

“Wash the tips of your crutches daily."

Answer and Explanation

The Correct Answer is B

A. "Maintain your head and neck erect when walking with crutches.": This is incorrect. The focus should be on posture and the use of crutches, not just the head and neck. Maintaining an erect posture is essential, but this option is too narrow and doesn’t provide full guidance on proper crutch use.

B. "Keep your elbows flexed at a 35° angle when using the crutches.": This is correct. The elbows should be slightly bent, approximately at a 30- to 35-degree angle, to ensure proper use of the crutches. This position prevents excessive strain on the shoulders and wrists while providing effective support.

C. "Support your body weight by leaning on the crutches.": This is incorrect. The crutches should not bear the entire weight of the body. Instead, the weight should be distributed through the arms and hands with the crutches supporting some of the load. Leaning on the crutches can lead to nerve damage or further injury.

D. “Wash the tips of your crutches daily.": This is incorrect. While it is important to keep crutches clean, washing the tips daily is unnecessary. It is more important to check the crutches for wear and tear and ensure the rubber tips are intact and provide proper traction.

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Correct Answer is B

Explanation

A. "Take an extra dose of insulin lispro prior to aerobic exercise." This is incorrect. Exercise can increase insulin sensitivity, meaning the client may need to reduce the dose of short-acting insulin (such as insulin lispro) before exercise to avoid hypoglycemia. The nurse should not recommend taking an "extra" dose of insulin prior to exercise.

B. "Draw up the insulin lispro and insulin glargine in separate syringes." This is correct. Insulin lispro (a rapid-acting insulin) and insulin glargine (a long-acting insulin) should never be mixed in the same syringe. Insulin glargine is acidic, and mixing it with other insulins can alter its action and effectiveness.

C. "Expect insulin glargine to be cloudy." This is incorrect. Insulin glargine should be clear and colorless. If insulin glargine appears cloudy, it may indicate that the insulin is expired or has been improperly stored.

D. "Anticipate that the insulin glargine will peak in 3 hours." This is incorrect. Insulin glargine has no pronounced peak. It provides a steady release of insulin over 24 hours and is designed to be taken once daily.

A. Count the client's respirations for 15 seconds. B. Place the client in a supine position. C. Inform the client when beginning to observe his respirations. D. Observe the movements of the client's chest wall.

Correct Answer is D

Explanation

A. "Count the client's respirations for 15 seconds" is incorrect. The nurse should count respirations for a full 60 seconds to ensure accuracy, especially in postoperative clients, as irregularities may be more easily detected with a longer observation period.

B. "Place the client in a supine position" is not necessary. While the position of the client can affect respiration, the nurse does not need to place the client in a supine position specifically to assess respirations. The client should be in a comfortable position that allows for adequate observation.

C. "Inform the client when beginning to observe his respirations" is incorrect. The client should not be aware that their respirations are being counted, as awareness can alter their breathing patterns and lead to inaccurate data.

D. "Observe the movements of the client's chest wall" is correct. Observing the chest wall allows the nurse to assess the rate, depth, and rhythm of respirations, as well as any signs of distress or abnormal patterns, which is crucial for monitoring postoperative respiratory status.

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A nurse is reinforcing teaching with a client who has an ankle injury and requires crutches. Which of the following instructions should the nurse provide?

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Naxlex Comprehensive Predictor Exams

A nurse is reinforcing teaching with a client who has diabetes mellitus and is taking insulin lispro and insulin glargine. Which of the following instructions should the nurse include in the teaching?

Correct Answer is B

Explanation

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Correct Answer is D

Explanation

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