Nokea
The nurse is teaching a client how to ambulate using crutches. Which of the following information should the nurse include?
- A. Keep the crutches 4 in (10 cm) in front of your feet while standing.
- B. When ascending stairs, lead with your unaffected (stronger) leg.
- C. Before sitting down in a chair, move both crutches to the unaffected (stronger) side of the body.
- D. Your shoulders should support your body weight while ambulating with crutches.
Correct Answer: B
Rationale: Leading with the stronger leg when ascending stairs ensures stability. Crutches should be 6-10 inches forward, crutches stay in both hands when sitting, and weight is on hands, not shoulders.
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The nurse is caring for a client with right-sided weakness. When transferring the client from the bed to a wheelchair, which action should the nurse perform?
- A. Place the wheelchair as close to the bed as possible on the client's unaffected side
- B. Place the wheelchair as close to the bed as possible on the client's affected side.
- C. Remove any nonskid slippers from the client's feet
- D. Gently pull on the client's arm to assist them to the side of the bed
Correct Answer: A
Rationale: Placing the wheelchair on the unaffected side (left) allows the client to pivot on their stronger side. Affected-side placement, removing slippers, or pulling the arm risk injury or falls.
The emergency department (ED) nurse is caring for a client with a head injury following a car accident. After a hyphema has been noted, the nurse should position the client
- A. Supine.
- B. Semi-Fowler's.
- C. Lateral on the affected side.
- D. Lateral on the unaffected side.
Correct Answer: B
Rationale: Semi-Fowler’s position (30-45 degrees) reduces intraocular pressure in hyphema, preventing complications. Supine or lateral positions may increase pressure.
The nurse is assisting a client with the use of a fracture bedpan. Which action should the nurse take?
- A. Position the client prone while placing the bedpan.
- B. Raise the head of the bed to 30 degrees.
- C. Place the open rim of the bedpan toward the head of the bed.
- D. Lower all of the side rails
Correct Answer: B
Rationale: Raising the head of the bed to 30 degrees facilitates client comfort and proper positioning for a fracture bedpan. Prone positioning is incorrect, the open rim faces the foot of the bed, and lowering all side rails is unsafe.
The nurse is caring for a client immediately following hypophysectomy. The nurse should position the client
- A. Trendelenburg
- B. Side-lying
- C. high-Fowler's
- D. Reverse Trendelenburg
Correct Answer: C
Rationale: High-Fowler’s position (head elevated 30–45 degrees) is recommended post-hypophysectomy to reduce intracranial pressure and prevent cerebrospinal fluid leakage. Trendelenburg and reverse Trendelenburg could increase pressure or disrupt surgical site healing, and side-lying is less effective for this purpose.
The nurse is caring for a client with an indwelling urinary catheter connected to a drainage bag. The nurse demonstrates effective care when. Select all that apply.
- A. Emptying the drainage bag when it is half full.
- B. Collecting a urine specimen for culture from the port in drainage tubing.
- C. Clamping the urinary catheter tubing prior to discontinuation.
- D. Instructing the client to carry the collection bag above their bladder during ambulation.
- E. The tubing goes in and out of the urethra during cleaning.
Correct Answer: A,B
Rationale: Emptying when half full prevents reflux, and collecting from the port ensures sterility. Clamping is unnecessary, carrying above the bladder risks reflux, and tubing movement risks infection.