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 C

Explanation

A. Elevated blood pressure: Diabetic ketoacidosis (DKA. typically does not cause elevated blood pressure. In fact, due to dehydration from increased urination, clients often present with hypotension or normal blood pressure, rather than hypertension.

B. Bounding pulse: A bounding pulse is not commonly associated with DKA. It may be seen with conditions such as fever or sepsis, but DKA is more likely to cause a weak or thready pulse due to fluid volume deficit and dehydration.

C. Fruity breath odor: A fruity or acetone-like breath odor is a hallmark sign of diabetic ketoacidosis. This is caused by the presence of ketones in the blood, which are produced as the body breaks down fat for energy when glucose is unavailable.

D. Clammy skin: Clammy skin is more likely to be associated with hypoglycemia, not DKA. In DKA, the skin is typically dry due to dehydration, and the client may appear flushed, not clammy.

A. WBC 13,000/mm3 B. Potassium 3.7 mEq/L C. Hgb 20 g/dL D. Iron 150 mcg/dL

Correct Answer is C

Explanation

A. WBC 13,000/mm3 is slightly elevated and might indicate an infection, but it is not critically high in the context of COPD. The nurse should still monitor the client for signs of infection but is unlikely to require immediate intervention.

B. Potassium 3.7 mEq/L is within the normal range (3.5–5.0 mEq/L) and does not require reporting.

C. Hgb 20 g/dL is elevated and should be reported. High hemoglobin levels can indicate dehydration, polycythemia, or other conditions related to chronic hypoxia, which is common in COPD. This value is above the normal range (12–18 g/dL for adults) and requires further evaluation.

D. Iron 150 mcg/dL is within the normal range (50–170 mcg/dL for adults) and does not require reporting.

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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?

Nursing Test Bank

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