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A nurse in an emergency department is providing discharge teaching to a
client who has a knee injury and will be using a pair of axillary crutches for
the first time. Which of the following instructions should the nurse include?
A. "Lean on the crutches to support your body weight when standing."
B. "Fully extend your arms when holding onto the hand grips."
C. "Hold the crutches on your unaffected side when preparing to sit in a
chair."
D. "Hold the crutches 9 inches in front of and to the side of each foot." ✔✔-
C. "Hold the crutches on your unaffected side when preparing to sit in a
chair."
,Rationale: The crutches should be held on the unaffected side when
preparing to sit in a chair.
A nurse stands facing a client to demonstrate active range-of-motion
exercises. Which of the following actions should the nurse take to
demonstrate hyperextension of the hip?
A. Move their leg behind their body.
B. Move their leg forward and up.
C. Move their leg medially toward their other leg.
D. Turn their foot and leg away from their other leg. ✔✔- A. Move their leg
behind their body.
Rationale: This movement demonstrates hyperextension of the hip.
A nurse is caring for a client who has a prescription for knee-length
antiembolic stockings. Which of the following actions should the nurse
take?
, A. Place the stockings on the client after the client ambulates to the
restroom.
B. Ensure the client's toes are visible after placing the stockings on the
client.
C. After applying the stockings, place two fingers between the client's leg
and stocking to check the fit.
D. Measure the client's calf circumference and leg length from heel to knee.
✔✔- D. Measure the client's calf circumference and leg length from heel to
knee.
Rationale: To ensure proper fit, the nurse should measure the widest part
of the client's calf as well as the length of client's leg from heel to knee.
Antiembolic stockings that are too large will not apply the pressure needed
to prevent DVT. Antiembolic stockings that are too small could impair
circulation in the client's legs.