The nurse is demonstrating three point gait crutch walking to an older adult client who broke a foot while playing soccer with the grandchildren. Which behavior Indicates that the client understands proper crutch walking?
Progresses to foot touchdown and weight bearing of affected leg.
Practices bicep and triceps isometric exercises.
Inspects crutches to ensure rubber tips are intact.
Bears body weight on the palms of hands during the crutch gait.
None
None
The Correct Answer is D
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Advise the UAP to wear a standard face mask to obtain vital signs, and then get fitted for a filter mask before providing personal care:
This option might be tempting but is not appropriate because the UAP should be properly equipped with the correct protective gear before any contact with the client. Bacterial meningitis requires droplet precautions, and a standard face mask is sufficient for this type of precaution, not a particulate filter mask.
B. Send the UAP to be fitted for a particulate filter mask immediately so the UAP can provide care to this client:
This action is unnecessary because bacterial meningitis requires droplet precautions, which only necessitate a standard surgical mask, not a particulate filter mask like an N95, which is used for airborne precautions. This option indicates a misunderstanding of the type of precautions needed for bacterial meningitis.
C. Instruct the UAP that a standard face mask is sufficient to be able to provide care for the assigned client:
This is the correct course of action. Bacterial meningitis requires droplet precautions, which only require a standard face mask. The UAP can safely provide care using a standard mask.
D. Before changing assignments, determine which staff members have fitted particulate filter masks:
While it is prudent to know which staff members are fitted for particulate filter masks, this is not necessary for caring for a client with bacterial meningitis under droplet precautions. The focus should be on ensuring the UAP understands that a standard mask is sufficient.
Correct Answer is C
Explanation
A. Initiate the facility's restraint flow sheet:
- Initiating the facility's restraint flow sheet is an important step for documenting the use of restraints according to institutional policies and regulatory requirements. However, in this scenario where improper use of restraints has been observed, the immediate priority is to address the safety concern and prevent harm to the client.
B. Ensure that the restraints are not too tight:
- Ensuring that the restraints are not too tight is crucial for preventing harm to the client, such as compromised circulation or tissue damage. However, while important, this action is secondary to addressing the observed improper use of restraints, which poses an immediate safety risk to the client.
C. Demonstrate proper securing of the restraints:
Educating the UAP on how to correctly apply restraints is crucial. Incorrectly secured restraints can lead to complications such as injury, infection, or impaired circulation. The nurse should show the UAP how to secure the restraints to amovable part of the bed frame, not to the side rails. This ensures safety and prevents harm if the side rails are released.Proper restraint application helps maintain the client’s safety while minimizing risks.
D. Complete an adverse occurrence/incident report:
- Completing an adverse occurrence/incident report: Reporting incidents is necessary, but it can wait until after ensuring safe restraint application.
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