Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
A nurse is providing teaching about the use of crutches using a three-point gait to a client who has a tibia fracture.
Which of the following actions by the client indicates an understanding of the teaching?
A. Moving both crutches with the stronger leg forward first.
Moving both crutches with the stronger leg forward first is incorrect for a three-point gait.This describes a two-point gait,which is used when a client can bear weight on both legs.In a three-point gait,the client bears weight on the unaffected leg and the crutches,not the stronger leg. This action would put excessive weight on the affected leg and could potentially compromise healing or cause further injury.
B. Supporting his body weight while leaning on the axillary crutch pads
Supporting his body weight while leaning on the axillary crutch pads is also incorrect.This can lead to nerve damage in the armpits and should be avoided. The weight should be distributed through the hands and wrists,not the armpits.
C. Stepping with his affected leg first when going up stairs
Stepping with his affected leg first when going up stairs is incorrect and potentially dangerous.The client should lead with the stronger leg when going up stairs to maintain balance and control.
D. Positioning both hands on the grips with his elbows slightly flexed.
Positioning both hands on the grips with his elbows slightly flexed is the correct action for using crutches with a three-point gait.This allows for proper weight distribution,balance,and control of the crutches. It also helps to prevent fatigue and strain in the arms and shoulders. Key points to remember about the three-point gait: Weight is borne on the unaffected leg and the crutches,not the affected leg. The crutches and the unaffected leg move forward together,followed by the affected leg. The client should look ahead,not down at their feet. The client should take small,even steps. The client should rest as needed.
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Full Explanation
The correct answer is Choice d. Positioning both hands on the grips with his elbows slightly flexed.
Choice A rationale:
- Moving both crutches with the stronger leg forward first is incorrect for a three-point gait. This describes a two-point gait, which is used when a client can bear weight on both legs. In a three-point gait, the client bears weight on the unaffected leg and the crutches, not the stronger leg.
- This action would put excessive weight on the affected leg and could potentially compromise healing or cause further injury.
Choice B rationale:
- Supporting his body weight while leaning on the axillary crutch pads is also incorrect. This can lead to nerve damage in the armpits and should be avoided.
- The weight should be distributed through the hands and wrists, not the armpits.
Choice C rationale:
- Stepping with his affected leg first when going up stairs is incorrect and potentially dangerous. The client should lead with the stronger leg when going up stairs to maintain balance and control.
Choice D rationale:
- Positioning both hands on the grips with his elbows slightly flexed is the correct action for using crutches with a three-point gait. This allows for proper weight distribution, balance, and control of the crutches.
- It also helps to prevent fatigue and strain in the arms and shoulders.
Key points to remember about the three-point gait:
- Weight is borne on the unaffected leg and the crutches, not the affected leg.
- The crutches and the unaffected leg move forward together, followed by the affected leg.
- The client should look ahead, not down at their feet.
- The client should take small, even steps.
- The client should rest as needed.
Similar Questions
A nurse is developing a care plan for a client who is in Buck’s traction and is scheduled for surgery for a fractured femur of the right leg.
Which of the following interventions should the nurse delegate to an assistive personnel?
A. Observe the position of the suspended weight
Observing the position of the suspended weight is beyond the scope of practice for assistive personnel (AP). This task requires assessment skills to ensure proper alignment and functioning of the traction system, which is the responsibility of the nurse.
B. Check the client’s pedal pulse on the right leg
Checking the client's pedal pulse on the right leg is essential for monitoring circulation in the affected limb. Any changes in pulse quality or absence of a pulse could indicate a serious complication, such as compartment syndrome. This assessment should be performed by the nurse to ensure accurate findings and timely intervention if needed.
C. Ask the client to describe her pain
Asking the client to describe her pain is part of the nursing assessment and should be done by the nurse. The nurse needs to assess the client's pain level, location, and characteristics to develop an appropriate pain management plan. Delegating this to assistive personnel could lead to inaccurate or incomplete information.
D. Remind the client to use the incentive spirometer
Reminding the client to use the incentive spirometer is a non-assessment task that involves reinforcing previously taught instructions. This is appropriate to delegate to assistive personnel, as it does not require clinical judgment.
E. None
None
F. None
None
Full Explanation
The correct answer is D. Remind the client to use the incentive spirometer.
Choice A rationale:
Observing the position of the suspended weight is beyond the scope of practice for assistive personnel (AP). This task requires assessment skills to ensure proper alignment and functioning of the traction system, which is the responsibility of the nurse.
Choice B rationale:
Checking the client’s pedal pulse on the right leg involves assessment and clinical judgment to evaluate perfusion and detect potential complications such as impaired circulation. This is not a task that can be delegated to AP.
Choice C rationale:
Asking the client to describe her pain requires assessment and interpretation of subjective data, which falls under the nurse's scope of practice. Pain assessment is a critical nursing function.
Choice D rationale:
Reminding the client to use the incentive spirometer is a non-assessment task that involves reinforcing previously taught instructions. This is appropriate to delegate to assistive personnel, as it does not require clinical judgment.
A nurse is reinforcing teaching with a parent of a 4-month-old infant during a home visit.
Which of the following statements by the parent indicates an understanding of the teaching?
A. I will use a cool-mist vaporizer in my baby's room.
This statement demonstrates an understanding of the teaching. Using a cool-mist vaporizer can help maintain moisture in the air and alleviate nasal congestion in infants.
B. I will leave my baby's bib on while he is sleeping.
This statement indicates a lack of understanding. It is not safe to leave a bib on an infant while they are sleeping as it can pose a suffocation risk.
C. I will leave the plastic covering on the crib mattress.
This statement indicates a lack of understanding. The plastic covering on the crib mattress should be removed as it can pose a suffocation hazard.
D. I will lay my baby's head on a pillow while he is in the crib.
This statement indicates a lack of understanding. Pillows should not be used in the crib for infants as they can increase the risk of suffocation and SIDS (Sudden Infant Death Syndrome).
Full Explanation
Explanation:
"I will use a cool-mist vaporizer in my baby's room." This statement demonstrates an understanding of the teaching. Using a cool-mist vaporizer can help maintain moisture in the air and alleviate nasal congestion in infants.
Incorrect:
B- "I will leave my baby's bib on while he is sleeping." This statement indicates a lack of understanding. It is not safe to leave a bib on an infant while they are sleeping as it can pose a suffocation risk.
C- "I will leave the plastic covering on the crib mattress." This statement indicates a lack of understanding. The plastic covering on the crib mattress should be removed as it can pose a suffocation hazard.
D- "I will lay my baby's head on a pillow while he is in the crib." This statement indicates a lack of understanding. Pillows should not be used in the crib for infants as they can increase the risk of suffocation and SIDS (Sudden Infant Death Syndrome).
A nurse is receiving change-of-shift report for a group of clients.
Which of the following clients should the nurse plan to assess first?
A. client who has a hip fracture and a new onset of tachypnea
. A client who has a hip fracture and a new onset of tachypnea. This client has a high risk of developing a pulmonary embolism, which is a life-threatening condition that requires immediate intervention. Tachypnea is a sign of respiratory distress and hypoxia, which can indicate a pulmonary embolism.
B. client who has diabetes mellitus and an HbA1c of 6.8%.
is wrong because a client who has diabetes mellitus and an HbA1c of 6.8% is wellcontrolled and does not need urgent attention. The normal range for HbA1c is 4% to 6%, and the goal for diabetic clients is less than 7%.
C. A client who has epidural analgesia and weakness in the lower extremities
wrong because a client who has epidural analgesia and weakness in the lower extremities is expected to have some degree of motor impairment due to the medication. The nurse should monitor the client’s sensation, movement, and pain level, but this is not a priority over choice A
D. A client who has sinus arrhythmia and is receiving cardiac monitoring
wrong because a client who has sinus arrhythmia and is receiving cardiac monitoring is not in immediate danger. Sinus arrhythmia is a normal variation of heart rhythm that occurs with breathing.
Full Explanation
The correct answer is choice A. A client who has a hip fracture and a new onset of tachypnea.
This client has a high risk of developing a pulmonary embolism, which is a life-threatening condition that requires immediate intervention.
Tachypnea is a sign of respiratory distress and hypoxia, which can indicate a pulmonary embolism.
The nurse should assess this client first and notify the provider.
Choice B is wrong because a client who has diabetes mellitus and an HbA1c of 6.8% is wellcontrolled and does not need urgent attention.
The normal range for HbA1c is 4% to 6%, and the goal for diabetic clients is less than 7%.
Choice C is wrong because a client who has epidural analgesia and weakness in the lower extremities is expected to have some degree of motor impairment due to the medication.
The nurse should monitor the client’s sensation, movement, and pain level, but this is not a priority over choice A. Choice D is wrong because a client who has sinus arrhythmia and is receiving cardiac monitoring is not in immediate danger.
Sinus arrhythmia is a normal variation of heart rhythm that occurs with breathing.
The nurse should observe the client’s vital signs and cardiac rhythm, but this is not a priority over choice A.
The correct answer is choice A. A client who has a hip fracture and a new onset of tachypnea.
This client has a high risk of developing a pulmonary embolism, which is a life-threatening condition that requires immediate intervention.
Tachypnea is a sign of respiratory distress and hypoxia, which can indicate a pulmonary embolism.
The nurse should assess this client first and notify the provider.
Choice B is wrong because a client who has diabetes mellitus and an HbA1c of 6.8% is wellcontrolled and does not need urgent attention.
The normal range for HbA1c is 4% to 6%, and the goal for diabetic clients is less than 7%.
Choice C is wrong because a client who has epidural analgesia and weakness in the lower extremities is expected to have some degree of motor impairment due to the medication.
The nurse should monitor the client’s sensation, movement, and pain level, but this is not a priority over choice A. Choice D is wrong because a client who has sinus arrhythmia and is receiving cardiac monitoring is not in immediate danger.
Sinus arrhythmia is a normal variation of heart rhythm that occurs with breathing.
The nurse should observe the client’s vital signs and cardiac rhythm, but this is not a priority over choice A.