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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?

Inspects crutches to ensure rubber tips are intact.

Practices bicep and triceps isometric exercises.

Progresses to foot touchdown and weight-bearing of the affected leg.

Bears body weight on the palms of hands during the crutch gait.

Answer and Explanation

The Correct Answer is D

Choice A rationale

Inspecting crutches to ensure rubber tips are intact is important for safety, but it does not indicate an understanding of the proper crutch walking technique. Proper crutch walking involves using the crutches correctly to avoid injury and ensure mobility.

Choice B rationale

Practicing bicep and triceps isometric exercises can help strengthen the muscles needed for crutch walking, but it does not demonstrate an understanding of the actual crutch walking technique. The focus should be on how the crutches are used during walking.

Choice C rationale

Progressing to foot touchdown and weight-bearing of the affected leg is a part of the rehabilitation process, but it does not specifically indicate proper crutch walking technique. Proper crutch walking involves the correct use of crutches to support the body weight.

Choice D rationale

Bearing body weight on the palms of hands during the crutch gait is the correct technique for three-point gait crutch walking. This method ensures that the weight is distributed properly and reduces the risk of injury to the underarms and shoulders.

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A. Apply the client’s positive airway pressure device. B. Lift and lock the side rails in place. C. Remove dentures or other oral appliances. D. Elevate the head of the bed to a 45-degree angle.

Correct Answer is C

Explanation

Choice A rationale

Elevating the head of the bed to a 45-degree angle can help improve airway patency and reduce the risk of airway obstruction in clients with OSA. However, applying the positive airway pressure device (CPAP or BiPAP) takes precedence due to its direct impact on maintaining airway patency and preventing respiratory compromise.

Choice B rationale

Lifting and locking the side rails in place ensures the safety of the client but does not directly address the client’s OSA or the potential respiratory depression associated with opioid analgesic administration.

Choice C rationale

Applying the client’s positive airway pressure device is the most important intervention in this scenario. Clients with severe obstructive sleep apnea rely on positive airway pressure devices, such as continuous positive airway pressure (CPAP) or bilevel positive airway pressure (BiPAP), to maintain airway patency and prevent episodes of apnea during sleep. Applying the device before leaving the client alone ensures continuous support for effective breathing.

Choice D rationale

Removing dentures or other oral appliances may be necessary for client comfort and safety, but it is not directly related to managing OSA or preventing respiratory compromise associated with opioid analgesic administration.

A. Monitor the client’s white blood cell count. B. Send wound drainage for culture and sensitivity. C. Institute contact precautions for staff and visitors. D. Explain the purpose of a low bacteria diet. E. Use standard precautions and wear a mask.

Correct Answer is ["A","B","C"]

Explanation

Choice A rationale

Monitoring the client’s white blood cell count is essential to assess the presence and severity of infection. An elevated white blood cell count can indicate an ongoing infection, including MRSA.

Choice B rationale

Sending wound drainage for culture and sensitivity is crucial to identify the specific bacteria causing the infection and to determine the most effective antibiotics for treatment.

Choice C rationale

Instituting contact precautions for staff and visitors is necessary to prevent the spread of MRSA. This includes wearing gloves and gowns when entering the client’s room and ensuring proper hand hygiene.

Choice D rationale

Explaining the purpose of a low bacteria diet is not relevant to the management of MRSA infections. MRSA management focuses on infection control measures and appropriate antibiotic therapy.

Choice E rationale

Using standard precautions and wearing a mask is not specific to MRSA management. While standard precautions are always important, contact precautions are more relevant for preventing the spread of MRSA.

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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?

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Correct Answer is C

Explanation

Correct Answer is ["A","B","C"]

Explanation

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Take full exam for free 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?

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A nurse administers an opioid analgesic to a postoperative client who also has severe obstructive sleep apnea (OSA). Which intervention is most important for the nurse to implement before leaving the client alone?

Correct Answer is C

Explanation

A client who is paraplegic is admitted with a foul-smelling drainage from a sacral ulcer.The client is suspected to have a methicillin-resistant Staphylococcus aureus (MRSA) infection. Which nursing intervention(s) should the nurse include in the plan of care? Select all that apply.

Correct Answer is ["A","B","C"]

Explanation

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?

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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?