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A nurse is reinforcing teaching with a client who has crutches regarding the use of the three-point gait. Which of the following instructions should the nurse include?
- A. Stand with the crutch tips against the feet.
- B. Hold the arms straight when walking.
- C. Keep the crutches at the level of the axillae.
- D. Bear weight on the unaffected leg.
Correct Answer: D
Rationale: The three-point gait involves bearing weight on the unaffected leg while advancing crutches and the affected leg.
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A nurse is assisting with the care of a client who is experiencing dysphagia following a recent stroke. The nurse should initiate a referral to which of the following interprofessional team members?
- A. Speech-language pathologist
- B. Respiratory therapist
- C. Occupational therapist
- D. Registered dietitian
Correct Answer: A
Rationale: A speech-language pathologist specializes in evaluating and treating swallowing difficulties like dysphagia.
A nurse is preparing to set up a sterile field to change a sterile dressing on a client's abdominal wound. Identify the sequence of steps the nurse should take. (Move the steps, placing them in the order of performance.)
- A. Open the innermost lower flap of the sterile kit while standing away from the sterile field.
- B. Open each side flap of the sterile kit individually while pulling to the side.
- C. Prepare a dry work surface above the waist level.
- D. Open the outside cover of the sterile kit and remove the dust cover.
- E. Grasp the outermost flap of the sterile kit while opening away from the body.
Correct Answer: C,D,E,B,A
Rationale: C: Set up surface. D: Open cover. E: Open outermost flap. B: Open side flaps. A: Open innermost flap maintains sterility.
A nurse is caring for a client who is postoperative and is preparing to walk for the first time in several days. Which of the following instructions should the nurse give the client to prevent orthostatic hypotension?
- A. Dangle your legs over the side of the bed.
- B. Use your incentive spirometer.
- C. Increase your intake of protein.
- D. Perform regular isometric exercises.
Correct Answer: A
Rationale: Dangling legs before standing allows gradual adjustment to upright posture, reducing orthostatic hypotension risk.
A nurse is caring for a client who requires a sterile dressing change. The nurse should recognize that the surgical field has been contaminated if which of the following actions occur?
- A. The handle of a pair of sterile scissors is resting 5 cm (2 in) from the field's edge.
- B. A pair of sterile forceps is allowed to rest in a container of sterile water on the field.
- C. Unnecessary sterile items are placed on the field.
- D. The sterile solution is poured with the bottle held over the field.
Correct Answer: D
Rationale: Pouring with the bottle over the field risks contamination from the non-sterile bottle.
A nurse is caring for a client who refuses their morning dose of antihypertensive medication. The client tells the nurse, 'I'm not going to take this medication because it makes me sick and dizzy.' Which of the following actions should the nurse take first?
- A. Return the medication to the medication cabinet.
- B. Notify the provider of the client's refusal.
- C. Inform the client of the potential consequences of their refusal.
- D. Document the refusal in the client's medical record.
Correct Answer: C
Rationale: Educating about consequences first respects autonomy and may encourage compliance.