Nokea
The nurse is evaluating the crutch-walking technique of a patient who is to have no weight bearing on the right leg. Which of the following observations indicates that the patient can safely ambulate independently?
- A. The patient keeps the padded area of the crutch firmly in the axillary area when ambulating.
- B. The patient advances the right leg and both crutches together and then advances the left leg.
- C. The patient moves the left crutch with the left leg and then the right crutch with the right leg.
- D. The patient uses the bedside chair to assist in balance as needed when ambulating in the room.
Correct Answer: B
Rationale: When using crutches, patients are usually taught to move the assistive device and the injured leg forward at the same time and then to move the unaffected leg. Patients are discouraged from using furniture to assist with ambulation. The patient is taught to place weight on the hands, not in the axilla, to avoid nerve damage. If the 2- or 4-point gaits are to be used, the crutch and leg on opposite sides move forward, not the crutch and same-side leg.
You may also like to solve these questions
The nurse is caring for a patient who has had an open reduction and internal fixation (ORIF) of left lower leg fractures who indicates constant severe pain in the leg which is unrelieved by the prescribed morphine. Pulses are faintly palpable and the foot is cool. Which of the following actions should the nurse take next?
- A. Notify the health care provider.
- B. Assess the incision for redness.
- C. Reposition the left leg on pillows.
- D. Check the patient's blood pressure.
Correct Answer: A
Rationale: The patient's clinical manifestations suggest compartment syndrome and delay in diagnosis and treatment may lead to severe functional impairment. The data do not suggest problems with blood pressure or infection. Elevation of the leg will decrease arterial flow and further reduce perfusion.
The nurse is caring for a patient who has a cast in place after fracturing the radius and the patient asks when the cast can be removed. Which of the following information related to the length of time that the cast will need to remain in place should the nurse tell the patient?
- A. Several months
- B. At least 3 weeks
- C. Until swelling of the wrist has resolved
- D. Until x-rays show complete bony union
Correct Answer: B
Rationale: Bone healing starts immediately after the injury, but since ossification does not begin until 3 weeks postinjury, the cast will need to be worn for at least 3 weeks. Complete union may take up to a year. Resolution of swelling does not indicate bone healing.
The nurse is caring for a patient who arrives in the emergency department with ankle swelling and severe pain after twisting the ankle playing soccer. Which of the following prescribed collaborative interventions will the nurse implement first?
- A. Wrap the ankle and apply an ice pack.
- B. Administer naproxen 500 mg PO.
- C. Give acetaminophen with codeine.
- D. Take the patient to the radiology department for x-rays.
Correct Answer: A
Rationale: Immediate care after a sprain or strain injury includes the application of cold and compression to the injury to minimize swelling. The other actions should be taken after the ankle is wrapped with a compression bandage and ice is applied.
Before assisting a patient with ambulation on the day after a total hip replacement, which of the following actions is most important for the nurse to implement?
- A. Administer the ordered oral opioid pain medication.
- B. Instruct the patient about the benefits of ambulation.
- C. Ensure that the incisional drain has been discontinued.
- D. Change the hip dressing and document the wound appearance.
Correct Answer: A
Rationale: The patient should be adequately medicated for pain before any attempt to ambulate. Instructions about the benefits of ambulation may increase the patient's willingness to ambulate, but decreasing pain with ambulation is more important. The presence of an incisional drain or timing of dressing change will not affect ambulation.
The nurse is providing discharge teaching to a patient with a sprained right ankle. Which of the following information should be included in the teaching plan? (Select all that apply.)
- A. Elevate the limb.
- B. Use nonsteroidal anti-inflammatory drugs as required.
- C. Apply warm moist heat for 45 minutes, three times per day.
- D. Use an elastic bandage on the ankle during activity.
- E. Use ice alternating with heat 48 hours after the injury.
Correct Answer: A,B,D
Rationale: Teaching instructions for a sprain include elevation of the limb at all times, even during sleep, using NSAIDs for discomfort, and an elastic bandage during activity. Warm moist heat can be applied but it is not to exceed 30 minutes. Ice is only to be used during the initial 24-48 hours after the injury.