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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. Placing a client in restraints without having a healthcare provider’s order. B. Administering the medication to a client behind a closed curtain. C. Informing a client that the medication being administered is a vitamin. D. Enlisting security personnel to assist with restraining the client.

Correct Answer is A

Explanation

Choice A rationale

Placing a client in restraints without having a healthcare provider’s order is a violation of patient rights and safety protocols. Restraints should only be used when absolutely necessary and with proper authorization to ensure the safety and well-being of the patient. Unauthorized use of restraints can lead to physical and psychological harm, and it is essential to follow established guidelines and obtain the necessary orders before applying restraints.

Choice B rationale

Administering the medication to a client behind a closed curtain is not a violation. This action ensures the client’s privacy and dignity during the administration of medication. Maintaining privacy is a standard practice in healthcare settings to respect the patient’s confidentiality and comfort.

Choice C rationale

Informing a client that the medication being administered is a vitamin is a violation of ethical and legal standards. It is essential to provide accurate information to the patient about the medication being administered. Misleading the patient can undermine trust and lead to potential harm if the patient has allergies or contraindications to the medication.

Choice D rationale

Enlisting security personnel to assist with restraining the client is not a violation if done appropriately. In situations where the client poses a danger to themselves or others, it may be necessary to involve security personnel to ensure safety. However, this should be done following proper protocols and with the necessary orders in place.

A. Tests for a gag reflex before performing oral care. B. Places the client in a supine position. C. Suctions secretions from the posterior pharynx. D. Uses an oral airway to keep the teeth apart.

Correct Answer is B

Explanation

Choice A rationale

Testing for a gag reflex before performing oral care is a standard practice to ensure the client’s safety and prevent aspiration. This action does not indicate a need for additional training.

Choice B rationale

Placing the client in a supine position is incorrect and indicates a need for additional training. The correct position for performing oral care on an unconscious client is a side-lying position to prevent aspiration and ensure secretions can drain from the mouth.

Choice C rationale

Suctioning secretions from the posterior pharynx is a necessary action to maintain airway patency and prevent aspiration. This action does not indicate a need for additional training.

Choice D rationale

Using an oral airway to keep the teeth apart is a standard practice to facilitate oral care and prevent the client from biting down on the caregiver’s fingers or equipment. This action does not indicate a need for additional training.

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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 A

Explanation

Correct Answer is B

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 is preparing to give an emergency sedative injection to an agitated client. Which action by the nurse comprises a violation?

Correct Answer is A

Explanation

The nurse observes a practical nurse (PN) performing oral care on an unconscious client. Which action by the PN indicates to the nurse the need for additional training?

Correct Answer is B

Explanation

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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?