A nurse should teach which of the following clients requiring crutches about how to use a three-point gait?

A client who is able to bear full weight on both lower extremities.

A client who has bilateral knee replacements with partial weight bearing on both legs.

A client who has a right femur fracture with no weight bearing on the affected leg.

A client who has bilateral leg braces due to paralysis of the lower extremities.

Answer and Explanation

The Correct Answer is C

A reason: A client who is able to bear full weight on both lower extremities. A client who can bear full weight on both lower extremities does not need to use a three-point gait. This gait is designed for individuals who cannot bear weight on one leg, making this choice incorrect for the given scenario.

B reason: A client who has bilateral knee replacements with partial weight bearing on both legs. A client with bilateral knee replacements and partial weight bearing needs a different type of gait that distributes weight evenly across both legs. The three-point gait is not suitable for this condition, thus making this choice inappropriate.

C reason: A client who has a right femur fracture with no weight bearing on the affected leg. A three-point gait is specifically used for individuals who are unable to bear weight on one leg. This gait involves using crutches and the unaffected leg to form a tripod, which provides stability while moving. Therefore, this option is the correct choice.

D reason: A client who has bilateral leg braces due to paralysis of the lower extremities. A client with bilateral leg braces due to paralysis would require a different gait pattern that accommodates the use of braces and supports for both legs. The three-point gait is not designed for bilateral leg paralysis, making this choice incorrect.

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Correct Answer is B

Explanation

A reason:

A client with a history of atrial fibrillation on continuous ECG monitoring requires close monitoring, but this can be done remotely. They do not necessarily need to be closest to the nurses' station.

B reason:

A client who sustained a head injury and is having periods of confusion should be assigned to the room closest to the nurses' station. This client requires frequent monitoring and quick access to medical staff due to the risk of worsening confusion or other complications.

C reason:

A client with a severe migraine headache needs a quiet environment and supportive care but does not require the same level of close monitoring as the client with confusion.

D reason:

A client with a suspected diagnosis of TB should be in a negative pressure room to prevent the spread of infection, which is typically not located closest to the nurses' station.

A. Withdraw 3 to 5 mL of urine from the port B. Insert the needle into the needleless port at a 60-degree angle C. Wipe the area of the needleless port with sterile water D. Don sterile gloves

Correct Answer is A

Explanation

A reason:

Withdrawing 3 to 5 mL of urine from the port is correct. This amount is typically sufficient for a culture and sensitivity test. It ensures that a fresh sample is obtained for accurate testing.

B reason:

Inserting the needle into the needleless port at a 60-degree angle is incorrect. Most needleless ports are designed to be accessed straight on, not at an angle, to prevent damage to the port.

C reason:

Wiping the area of the needleless port with sterile water is incorrect. The port should be cleaned with an antiseptic solution, such as alcohol, to disinfect the area and prevent contamination of the urine sample.

D reason:

Donning sterile gloves is not typically required for this procedure. Clean gloves are usually sufficient unless the protocol specifies otherwise. The priority is to ensure aseptic technique when handling the catheter and obtaining the sample.

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A nurse should teach which of the following clients requiring crutches about how to use a three-point gait?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is A

Explanation

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