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A client with lower extremity weakness is being taught a four-point crutch gait by a nurse. Which of the following instructions should the nurse include in the teaching?
- A. Bear weight on both legs.
- B. Move the crutches and the weak leg in unison.
- C. Advance the crutches and the strong leg simultaneously.
- D. Move the crutches forward, then move one leg at a time.
Correct Answer: D
Rationale: The correct technique for a four-point crutch gait involves moving the crutches forward, then moving one leg at a time. This method provides stability and support by alternating movement between the crutches and legs. Choice A is incorrect because bearing weight on both legs simultaneously is not the correct method for a four-point gait. Choice B is incorrect as moving the crutches and weak leg together does not provide the required stability. Choice C is incorrect as advancing the crutches and strong leg together does not promote the alternating movement needed for a four-point gait.
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A nurse receives a prescription for an antibiotic for a client with cellulitis. The nurse checks the client's medical record, discovers the client's allergy to the antibiotic, and calls the provider for a different prescription. Which of the following critical thinking attitudes did the nurse demonstrate?
- A. Fairness
- B. Responsibility
- C. Risk-taking
- D. Creativity
Correct Answer: B
Rationale: The nurse demonstrated responsibility by recognizing the potential harm of administering an antibiotic the client is allergic to and taking the necessary steps to ensure the client's safety. Choice A, 'Fairness,' is not applicable in this scenario as it does not involve treating individuals equitably. Choice C, 'Risk-taking,' is incorrect as the nurse's actions aimed to minimize risks rather than taking them. Choice D, 'Creativity,' is not the best fit as the nurse's actions focused on following established protocols and ensuring patient safety rather than thinking innovatively.
When reviewing EBP about the administration of O2 therapy, what is the recommended maximum flow rate for regulating O2 via nasal cannula?
- A. Regulate O2 via nasal cannula no more than 6L
- B. Regulate O2 via nasal cannula no more than 2L
- C. Regulate O2 via nasal cannula no more than 4L
- D. Regulate O2 via nasal cannula no more than 8L
Correct Answer: A
Rationale: The correct answer is to regulate O2 via nasal cannula no more than 6L. This flow rate is generally recommended to ensure adequate oxygen delivery without causing discomfort or potential harm to the patient. Choices B, C, and D are incorrect as they suggest flow rates that are either too low (2L, 4L) or too high (8L). A flow rate of 2L might not provide sufficient oxygen, while 4L could be inadequate for some patients. On the other hand, a flow rate of 8L could be excessive and potentially harmful, leading to complications like oxygen toxicity. Therefore, the optimal recommendation is to regulate O2 via nasal cannula at a maximum of 6L to balance effectiveness and safety.
A client has a terminal diagnosis and their health is declining. The client requests information about advance directives. Which of the following responses should the nurse make?
- A. Offering to discuss advance directives and provide brochures respects the client's request and provides information.
- B. Informing the client that advance directives are not necessary at this time is incorrect as they play a crucial role in end-of-life care.
- C. Scheduling a meeting with the family to discuss advance directives is not the most appropriate response as the client directly requested information.
- D. Directing the client to ask their provider about advance directives does not directly address the client's request for information.
Correct Answer: A
Rationale: When a client with a terminal illness asks about advance directives, it is essential to provide the information they seek. Choice A is the correct response as it acknowledges the client's request and offers to discuss advance directives while providing additional resources in the form of brochures. This approach empowers the client to make informed decisions about their end-of-life care. Choices B, C, and D are incorrect because they do not directly address the client's request or provide the information the client is seeking. Choice B dismisses the importance of advance directives, which are crucial in end-of-life care planning. Choice C involves the family unnecessarily when the client directly requested information. Choice D deflects the responsibility back to the client to seek information from their provider instead of addressing their immediate request.
A client is on bed rest following an abdominal surgery. Which of the following findings indicates the need to increase the frequency of position changes?
- A. Flat rash on the client's ankle
- B. Non-blanching red area over the client's trochanter
- C. Ecchymosis on the client's left shoulder
- D. Petechiae on the client's right anterior thigh
Correct Answer: B
Rationale: The presence of a non-blanching red area over the client's trochanter is a concerning finding as it indicates possible pressure ulcer formation. This finding necessitates an increase in the frequency of position changes to prevent skin breakdown. Choices A, C, and D do not directly correlate with the need for increased position changes. A flat rash, ecchymosis, and petechiae may have different causes and would not be addressed by changing the client's position more frequently.
When a nurse instructs a client with hearing loss about cleaning their new hearing aids, which statement indicates that the client understands the instructions?
- A. I use a damp cloth to clean the outside part of my hearing aids.
- B. I clean my hearing aids' ear molds with rubbing alcohol.
- C. I always keep the volume of my hearing aids turned up for better hearing.
- D. I remove the batteries from my hearing aids when not in use at night.
Correct Answer: A
Rationale: The correct answer is A because cleaning the outside part of hearing aids with a damp cloth is an appropriate method. Rubbing alcohol can damage ear molds, so choice B is incorrect. Keeping the volume of hearing aids turned up high may lead to discomfort, making choice C incorrect. Removing batteries when not in use at night is good practice for battery life, but it does not directly relate to understanding cleaning instructions, so choice D is less relevant in this context.