*HURST REVIEW Qbank/Customize Quiz - Basic Care and Comfort

The nurse is caring for a client immediately following a bilateral salpingo-oophorectomy. Which position would be best for this client? 1. Fowler's 2. Modified Sims 3. Side-lying 4. Supine

3. Correct: We want to position for comfort with the knees flexed and on the side for airway. 1. Incorrect: Avoided to prevent pooling and edema in pelvis. 2. Incorrect: Partial lying on stomach is going to be painful. 4. Incorrect: Stretching out straight puts pressure on the abdomen and should be avoided.

Which food items, if chosen by a new unlicensed assistive personnel (UAP), would indicate to the nurse that the UAP understands a clear liquid diet? Select all that apply 1. White grape juice 2. Gelatin 3. Vanilla pudding 4. Lemon Popsicle 5. Fat free Broth 6. Tea with honey

1., 2., 4., 5., & 6. Correct: A clear liquid diet is made up of only clear fluids and foods that are clear fluids when they are at room temperature. These choices are considered to be clear liquids. 3. Incorrect. This is considered appropriate for a full liquid diet.

The nurse is assisting a new mother with breastfeeding her newborn baby. The mother verbalizes concern that the baby is not getting adequate milk. Which observations by the nurse indicate adequate fluid intake? Select all that apply 1. Birth weight regained in 14 days 2. Fontanels soft and depressed 3. Pulse rate of 135/min 4. Six to eight wet diapers a day 5. Baby appears satisfied after feedings

1., 3., 4. & 5. Correct: Are all indicators of adequate fluid intake in a newborn. Gaining weight, a heart rate between 70 to 190 beats per minute (BMP), six to eight wet diapers a day and periods of contentment after feedings alternate with periods of wakefulness indicate adequate breastfeeding. 2. Incorrect: Fontanels should be soft, firm and flat. A depressed or sunken fontanel may indicate dehydration. Dehydration is one of the major causes of sunken fontanels.

Which nursing intervention will be most helpful to a middle-aged client experiencing insomnia? 1. Instruct the client to initiate an exercise routine during the day. 2. Educate the client on ways to adjust the sleep environment. 3. Instruct the client on progressive relaxation techniques to be used just before bedtime. 4. Instruct the client to decrease caffeine intake.

3. Correct: The use of progressive relaxation techniques would help the client relax before bedtime and promote sleep. 1. Incorrect: Exercise might be helpful, but not most helpful. 2. Incorrect: This intervention is not specific. 4. Incorrect: Instructing the client to decrease caffeine intake may help the client but not specific enough.

An infant has been prescribed Bryant's traction for a diagnosis of developmental dislocated hips (DDH). At what degree of hip flexion should the nurse maintain the infant's hip for proper traction alignment? 1. 15 2. 30 3. 45 4. 90

4. Correct: Bryant's traction is used for DDH. The child's body and the weights are used as tension to keep the end of the femur in the hip socket. Traction helps position the top of the femur into the hip socket correctly. This is accomplished with 90 degrees of hip flexion. 1. Incorrect: Fifteen degrees of flexion is not adequate to keep the femur end in the hip socket. 2. Incorrect: Thirty degrees of flexion is not adequate to keep the femur end in the hip socket. 3. Incorrect: Forty-five degrees of flexion is not adequate to keep the femur end in the hip socket.

A nurse is planning a teaching session for a group of clients diagnosed with irritable bowel syndrome. What points should the nurse include to help the clients control symptom flare-ups? Select all that apply 1. If you are constipated, try to make sure you have breakfast. 2. Avoid low fat foods. 3. If you think a certain food is a problem, try cutting it out of your diet for about 12 weeks. 4. Drinks containing caffeine are likely to contribute to symptoms. 5. Foods such as broccoli and cabbage are good sources of fiber.

1., 3. & 4. Correct: If you are constipated, try to make sure you eat breakfast, as this is the meal that is most likely to stimulate the colon and give you a bowel movement. If you think a certain food is a problem, try cutting it out of your diet for about 12 weeks. (If you suspect more than one, cut out one at a time so you know which one causes you problems.) If there's no change, go back to eating it. The foods most likely to cause problems are: Insoluble (cereal) fiber; Coffee/caffeine; Chocolate; Nuts. 2. Incorrect: Avoid meals that over-stimulate the gut, like large meals or high fat foods. 5. Incorrect: Broccoli and cabbage are common gas-producing foods that can cause abdominal distention and flatulence.

Which meal option should the client diagnosed with gout select? 1. Tuna salad on bed of lettuce, apple slices, coffee 2. Vegetable soup, whole wheat toast, skim milk 3. Roast beef with gravy sandwich, baked chips, diet coke 4. Spinach salad with chickpeas and asparagus, apple, tea

2. Correct: Gout is pain and inflammation that occurs when too much uric acid crystallizes and deposits in the joints. This is a good choose as it is low in purine and fat. Purines are broken down into uric acid. A diet rich in purines can raise uric acid levels. Meat and seafood increase the risk of gout. Dairy products may lower risk for gout. 1. Incorrect: The client should not eat tuna, which is high in purine. 3. Incorrect: Gravy is a high purine food and should be avoided. Also avoid artificial sweeteners. 4. Incorrect: Although spinach, and asparagus can be consumed in moderation, they still contain purines, so it is not as good of a choice as the vegetable soup, toast and skim milk.

The parents of a 4 year old child have recently had a new baby and the parents report that the 4 year old had been dry all night for 8 months and is now wetting the bed again. What should the nurse assess first? 1. Urinalysis 2. Normal urination habits. 3. Adjustment to the new baby. 4. Fluid intake after 6 pm.

1. Correct: Always assess the physiologic problem first to rule out a urinary tract infection (UTI). Once a physiologic cause is removed as the cause other assessment should be performed. If a UTI is present, treatment should start immediately. 2. Incorrect: Assessing the normal urination habits is not first. Assessing the urinalysis is priority. 3. Incorrect: Regression is the likely cause but the physiologic problems should be assessed first. 4. Incorrect: The child's fluid intake may be too high after 6 pm, but ruling out a urinary tract infection is the first assessment and requires immediate treatment if there is an infection.

A nurse is performing eye care for an unconscious client. Which interventions should the nurse include? Select all that apply 1. Administer moist compresses to cover eyes every 2 hours. 2. Clean eyes with saline and cotton balls, wiping from outer to inner canthus. 3. Use a new cotton ball for each cleansing wipe. 4. Instill artificial tears into the lower eyelids as prescribed. 5. Protect the eyes with a protective shield. 6. Monitor eyes for redness and exudate.

1., 3., 4., 5., & 6. Correct: All of these interventions are appropriate for eye care of the comatose client. These actions prevent infection, keep eyes moist, and protect the eye from injury. 2. Incorrect: Clean the eyes with saline solution and cotton balls. Wipe from the inner to outer canthus. This prevents debris from being washed into the nasolacrimal duct.

The nurse is teaching a client about the use of a cane. Which is the correct cane technique? 1. Place the cane on weaker side of the body to support the weaker leg. Using the cane for support, the client should step forward with strong leg, and then move the weaker leg and cane forward to the strong leg. 2. Place the cane on the stronger side of the body. The cane is placed forward 6 to 10 inches while the client advances the weak leg at the same time. 3. Place cane on weaker side of body. The cane is placed forward 6 to 10 inches while the client advances weaker leg to the cane. 4. Place cane on stronger side of body to help support weaker leg. Using cane for support, step forward with the strong leg and then move the weaker leg and the cane forward to the strong leg.

2. Correct: Place the cane on the stronger side of the body. The cane is placed forward 6 to 10 inches while the client advances the weak leg at the same time. The body weight is divided between the strong leg and the cane. 1. Incorrect: The cane should be on the stronger side of the body to create a wider base for balance as the client advances the strong leg and must use the weaker leg for support with the cane. If the cane is placed on the weaker side of the body, this would create a narrower base for support and balance and increase the risk of falling. 3. Incorrect: The cane should be on the stronger side of the body to create a wider base for balance as the client advances the strong leg and must use the weaker leg for support with the cane. If the cane is placed on the weaker side of the body, this would create a narrower base for support and balance and increase the risk of falling. 4. Incorrect: The cane should be on the stronger side of the body to create a wider base for balance as the client advances the strong leg and must use the weaker leg for support with the cane. If the cane is placed on the weaker side of the body, this would create a narrower base for support and balance and increase the risk of falling.

Which action by two unlicensed nursing personnel (UAPs), while moving the client back up in bed, would require intervention by the nurse? 1. Lowers the side rails closest to them. 2. Places hands under client's axilla. 3. Lowers the head of bed. 4. Raises the height of the bed.

2. Correct: This action is not appropriate and requires intervention by the nurse. This could damage the brachial plexus nerves under the axilla. Use a draw sheet to prevent this from occurring. 1. Incorrect: This is a correct action. The UAPs will need to lower the side rails closest to them to safely move the client up in bed. Not lowering the rails could injury the UAPs back. 3. Incorrect: This action is correct. Moving the client upward with the head of the bed raised works against gravity, requires more force and can cause back strain. 4. Incorrect: This action is appropriate and would not require intervention by the nurse. Raising the height of the bed brings the client close to the UAPs center of gravity and decreases the chance of back injury.

The nurse is repositioning a client who is in the supine position to the right lateral position. Which nursing intervention would be implemented to position the client in the right lateral position? 1. The right leg is positioned on a pillow in front of the left leg. 2. Both knees are kept in the extension position. 3. Both feet are placed in the inversion position. 4. The left shoulder should be positioned forward.

4. Correct: The left shoulder should be adducted. The position of adducting the shoulder forward promotes improved chest expansion and decreases strain on the shoulder. 1. Incorrect: The right leg is positioned forward in the left lateral position. For the right lateral position, the left leg is positioned on a pillow in front of the right leg. 2. Incorrect: Both legs should not be extended for the right lateral position. The left leg should be positioned forward with the knee flexed to decrease the internal rotation of the femur. 3. Incorrect: Inversion of the feet is described as positioning the ankles toward the midline of the body. The feet should be positioned in the neutral position to maintain proper ankle alignment.

The nurse observes an unlicensed assistive personnel (UAP) performing AM care for a client with a plaster leg cast applied 12 hours ago. Which action by the UAP should the nurse intervene? 1. Lifting the affected leg with the palms of the hands 2. Covering the affected leg with a blanket to avoid chills 3. Placing plastic over the entire cast prior to bathing 4. Elevating the casted leg on two pillows

2. Correct: Plaster cast take 24-48 hours to completely dry. During this time they release heat. The new cast should not be covered so that heat from the cast can evaporate. If the heat is not allowed to dissipate, drying will take longer. 1. Incorrect: Plaster cast take 24-48 hours to completely dry. During this time the cast should be handled carefully as to avoid indentations. Handling the cast carefully with the palms and not the fingertips will prevent indentations. Indentations in the cast could cause skin breakdown inside the cast. 3. Incorrect: Yes, will keep cast from getting wet. Plaster casts should never get wet. The plaster cast does not hold up well in water. Wet casts can also irritate the skin underneath. 4. Incorrect: Yes, may elevate the leg. Fractures are prone to swelling. Elevating fractures while casted is a common occurrence. Elevation prevents swelling.

A terminal client begins reminiscing about the past, expressing grief and regret over life choices. What response by the nurse would best help the client cope at this time? 1. "You can't change the past so try not to dwell on it." 2. "Would you like me to call a priest for you to talk with?" 3. "You still have time to make amends if you want." 4. "I can sit here with you while you continue to talk."

4. CORRECT: Anytime a client expresses the desire to talk, the nurse should respond with an open-ended response, encouraging the client to continue to verbalize in a non-judgmental environment. More importantly, the nurse should remain with the client, even if there is no talking, to provide visual comfort. 1. INCORRECT: This non-therapeutic response denies the client's right to review past events or express feelings, which is a normal reaction at end of life. The nurse's closed response does not provide the client with the opportunity to verbalize. 2. INCORRECT: The nurse is ignoring the client's need to talk and is transferring care away to another individual, even if that individual is a clergyman. This is an incorrect action. 3. INCORRECT: While the client may regret some life choices, there is no mention of the desire or need to correct the past. The nurse is making an assumption.

The nurse is planning care for four clients with different medical issues. With which diagnosis would a client benefit most from an integrative medicine healthcare strategy? 1. Chronic fatigue syndrome who has had no relief of fatigue. 2. Diabetes whose blood sugars are out of control and refuses to take the prescribed oral and injection medications. 3. Cholecystitis who wants surgery to treat the symptoms definitively. 4. Productive cough with green sputum, fever of 104.2 degrees Fahrenheit (40.1 degrees C), and chest pain.

1. Correct: Chronic fatigue syndrome is a chronic health problem that is difficult to treat using only traditional medicine and responds well to the use of an integrative medicine healthcare strategy by using a combination of traditional and holistic therapies. Integrative medicine is an approach to care that puts the patient at the center and addresses the full range of physical, emotional, mental, social, spiritual and environmental influences that affect a person's health. 2. Incorrect: Clients with acute illness symptoms are more appropriately treated with traditional medicine strategies. 3. Incorrect: Clients with acute illness symptoms are more appropriately treated with traditional medicine strategies. 4. Incorrect: Clients with acute illness symptoms are more appropriately treated with traditional medicine strategies.

The nurse is caring for a Puerto Rican client. The client has several injuries from a car accident and is experiencing pain. Which behavior is likely to be noted? 1. Loud crying with pain. 2. Enduring the pain in order to bring honor. 3. Quiet and stoic responses to pain. 4. Refusing pain medication because it is God's will.

1. Correct: Puerto Rican clients tend to cope with pain by loud and outspoken reports of pain. This is consistent with Puerto Rican culture and their response to pain. 2. Incorrect: Quietly enduring pain is consistent with the Japanese culture. This is consistent with the Asian culture and brings honor. 3. Incorrect: Stoic responses are consistent with Asian culture. The client is likely to be quiet about the pain thinking that complaints of pain will bring dishonor to the family. 4. Incorrect: Filipino clients tend to view pain as God's will. They may refuse medication to relieve the pain.

The primary healthcare provider has prescribed ear irrigation for a client with earwax accumulation. In what order would the nurse perform the procedure? Remove any debris in the outer canal. Squeeze syringe with moderate force. Aim syringe at back side of ear canal. Tilt client's head to the opposite side. Fill bulb syringe with lukewarm water. Pull ear pinna upward and backward. Drag and Drop the items from one box to the other

Ear wax is a substance produced by the body to clean and protect the ear canal. Usually, the ear is able to remove wax that has dried up and become useless. However, in certain circumstances, a nurse may receive a prescription to irrigate ears for clients when the wax has become impacted. After gathering the needed equipment and explaining the process to the client, the nurse should first fill the bulb syringe with warm water. Next, positioning the client is always the nurse's responsibility. For irrigating ears, the client's head should be tilted slightly toward to opposite side, so the affected ear is easily accessible. Third, using one hand, the nurse pulls the ear pinna gently upward and back to straighten the ear canal. Fourth, aim the bulb syringe toward the back and side of the ear canal. Next, the nurse squeezes the syringe with moderate force to flush out loose debris or dried wax. Sixth, any debris visible in the outer canal can be carefully removed with tweezers.

In what order will the nurse provide instructions to a client on using a cane? Advance weaker leg forward toward the cane. Move cane forward 6-10 inches (15 - 25 cm). With cane on stronger side of body, support body weight with both legs. Advance stronger leg forward toward cane. Drag and Drop the items from one box to the other

First, with cane on stronger side of body, support body weight with both legs. This will support the even distribution of weight away from the weaker side to promote a normal gait. Second, move cane forward 6-10 inches (15-25 cm). Moving the cane the approximate distance of a normal gait helps with stability. Third, advance weaker leg forward toward the cane. This allows the weight to be supported by the cane and the stronger leg. Fourth, advance stronger leg forward toward the cane. This allows the weight to be supported by the can and weaker leg.

A palliative care client is suffering from persistent diarrhea. What foods should the nurse suggest? Select all that apply 1. Applesauce 2. Rice 3. Bananas 4. Tea 5. Yogurt

1., 2., & 3. Correct: The BRAT diet is recommended for clients with persistent diarrhea. This diet consists of bananas, rice, applesauce, and toast. Rice and potatoes help to reduce diarrhea. Bananas will help replace potassium. Once the diarrhea subsides, the client can add easily digestible foods like eggs. 4. Incorrect: Avoid coffee and tea because caffeine containing beverages may have a laxative effect. Caffeine is a stimulant and will increase the peristalsis even more. 5. Incorrect: Dairy products may make the diarrhea worse. Avoid these until the diarrhea subsides.

An occupational health nurse is planning to teach a group of manufacturing workers how to prevent back injuries. What teaching points should the nurse plan to include? Select all that apply 1. Wear comfortable, low-heeled shoes. 2. When sitting, keep knees slightly lower than the hips. 3. Avoid movements that require spinal flexion with straight legs. 4. Squarely face the direction of anticipated movement. 5. Pivot to turn while holding an object.

1., 3., 4., & 5. Correct: Comfortable, low heeled shoes provide good foot support and reduce the risk of slipping, stumbling, or turning your ankle. Flexion of the spine with the legs straight (toe-touches, sit-ups) will injure the back. Avoid twisting of the back by squarely facing the direction of movement. Move toward or away from your center of gravity. Pivoting is a technique in which the body is turned in a way that avoids twisting of the spine. 2. Incorrect: When sitting, keep knees slightly higher than the hips.

What foods should the nurse teach a client who has been diagnosed with iron deficiency anemia to increase in the diet? Select all that apply 1. Chickpeas 2. Milk 3. Oysters 4. Raisins 5. Spinach 6. Tuna

1., 3., 4., 5., & 6. Correct: All of these are high in iron. 2. Incorrect: Milk is not high in iron and slows the absorption of iron.

An elderly client has been admitted to the hospital with a diagnosis of cerebral vascular accident (CVA) with right-sided paralysis. When the nurse instructs staff to reposition client every two hours, the family asks about the purpose of this action. What is the best explanation by the nurse? 1. Improves circulation to the affected side of the body. 2. Decreases potential skin breakdown from immobility. 3. Prevents blood stasis in the client's lower extremities. 4. Alleviates sensory deprivation by varying environment.

2. CORRECT. An immobile client is subjected to shearing forces and tissue breakdown because of prolonged contact between the skin and linens. Pressure sores can develop quickly when a client remains in one position over long periods of time, particularly on protruding areas of the body such as hips, elbows, sacrum or heels. Repositioning the client every two hours decreases the potential for skin breakdown and allows for inspection of all vulnerable body areas. 1. INCORRECT. While moving a paralyzed client might stimulate the overall circulation, and even allow for passive range of motion, repositioning a client does not specifically increase blood flow to one side of the body. 3. INCORRECT. Though moving a client can stimulate the circulation, repositioning every two hours is not sufficient to prevent blood stasis in lower extremities, particularly when this client cannot move the right side independently. 4. INCORRECT. Sensory deprivation is not a major concern for the client initially and repositioning is not meant to address sensory needs. The purpose of repositioning is prevention of skin breakdown.

A client diagnosed with advanced cirrhosis is admitted with dehydration and elevated ammonia levels. While discussing dietary issues, the client requests larger portions of meat with meals. Which response by the nurse provides the most accurate information to the client? 1. I will ask the dietician to add more meat with dinner. 2. Protein must be limited because of elevated ammonia levels. 3. You need to drink more fluids because of your dehydration. 4. We can ask for between meal snacks with more carbohydrates.

2. Correct: Normally, protein is broken down into ammonia, which the liver converts into urea, and the kidneys then easily excrete. However, in a diseased liver, this conversion is not possible, and ammonia continues to build up in the body, ultimately affecting the brain. The nurse would be aware that additional protein would be harmful for this client. 1. Incorrect: Increasing meat at mealtimes would be detrimental to the client's health. When protein is taken into the body, a healthy liver will convert this into urea that is then excreted by the kidneys. However, this client's impaired liver is not able to make that conversion; therefore, the ammonia levels would continue to increase. The nurse can discuss with the client other foods that might safely be added to meals. 3. Incorrect: While it is true this client is dehydrated, the issue is that the client wants to increase the amount of meat at mealtimes. This response does not address the client's request nor does it provide any teaching that would help the client once discharged. 4. Incorrect: Although this response indicates that the nurse is focusing on the client's issue with food, this reply does not address the request for more meat with meals. This would be the appropriate opportunity to educate the client on the need to limit daily protein in the diet.

A client being discharged home following hip surgery is prescribed to use a walker. While observing the client walk across the room, the nurse is most concerned when the client does what? 1. Applies shoes securely before ambulating with walker. 2. Checks walker to be certain the legs are securely locked. 3. Slides walker slowly forward when walking across the room. 4. Places walker to right of the chair after sitting down in chair.

3. CORRECT: The nurse is observing the client ambulate with a walker prior to discharge, to determine whether the client is using the assistive device safely. The nurse becomes concerned upon noting the client sliding the walker during ambulating. The correct use of a walker involves the client lifting and placing the walker approximately one-foot length ahead, then stepping into the non-moving walker. It is important for the walker to remain stationary when the client takes a step forward. 1. INCORRECT: This action by the client is appropriate. Proper, gripping footwear should be worn by the client at all times when ambulating. This prevents the possibility of slipping and falling. There is no cause for concern with this action. 2. INCORRECT: Another smart move is to verify the cross bars are securely locked before ambulating. When a walker is folded for storage, the locks are unlatched. When the walker is open, the locks must click into place to verify the device is safe for ambulating. No concerns here. 4. INCORRECT: When a client sits down, the walker can be placed to either side of the chair. The most important factor is for the client to use the walker to safely maneuver into the chair rather than placing the walker aside before sitting down. Placing the walker next to the chair after being seated is appropriate.

Which action would the nurse need to perform to increase stability while initiating a client transfer? 1. Lift with the back. 2. Put on a back belt. 3. Spread feet to width of the shoulders. 4. Lean forward slightly.

3. Correct: In order to increase stability, the nurse will need to increase the base of support. This can be done by spreading the legs to the width of the shoulders. 1. Incorrect: Do not use your back to do heavy lifting. They are not your strongest muscles. Use your legs. 2. Incorrect: A back belt will not increase the base of support. 4. Incorrect: The nurse should not lean forward or backward. The ears, shoulders, hips and feet should be aligned.

Which food item would the nurse include when planning diet instructions to promote bone growth for a client with a broken tibia? 1. Lettuce 2. Apples 3. Yogurt 4. Green beans

3. Correct: The serving size of 150 g of yogurt has a calcium content of 240 mg. 1. Incorrect: The serving size 50 g of lettuce has a calcium content of 19 mg. 2. Incorrect: The serving size of 182 g of apple has a calcium content of 11 mg. 4 Incorrect: The serving size of 90 g cooked green beans has a calcium content 50 mg.

The nurse is making an initial home visit to a client newly diagnosed with diverticulitis. The client had been on a liquid diet but is now to begin solid foods appropriate for the disease process. The nurse knows dietary teaching has been successful when the client selects which meal? 1. Hamburger on sesame roll, macaroni and cheese, tossed salad 2. Lamb chop with brown rice, cooked broccoli, baked potato 3. Pork with sauerkraut, baked beans, and coconut cake 4. Spaghetti with meatballs, fruit cocktail, garlic bread

4. CORRECT. Diverticulitis is an inflammation within the small, outpouching which can develop in the colon. A low residue/low fiber diet limits the amount of food waste passing through the large intestine, allowing the intestinal tract to rest and heal. Cooked pasta, along with ground, well cooked meatballs, is tolerated well. Canned fruits like fruit cocktail are far better than fresh fruit to control diarrhea and cramping. Garlic bread is also acceptable. 1. INCORRECT. A hamburger is well ground, cooked meat, which is acceptable for this client, but not when served on the sesame roll. Seeds and nuts tend to lodge in the diverticula, leading to pain or infection. Macaroni and cheese is a great menu item for the client. However, fresh vegetables, though healthy, do not breakdown easily, resulting in large amounts of undigested material passing through, or getting stuck, in the large intestine. 2. INCORRECT. Lamb is an acceptable as part of a low residue diet, but clients are instructed to eat white rice rather than the whole grain brown rice. Vegetables which create gas even when cooked, such as broccoli, could lead to a serious exacerbation of diverticulitis. Well cooked potatoes are permitted, but not if prepared with the skin, such as the baked potato. 3. INCORRECT. Several parts of this menu selection present a major problem for the client; in fact, only the pork is acceptable. Sauerkraut is prepared cabbage, and even when cooked, causes digestive and gas issues. Baked beans should be avoided for the same digestive reasons, and coconut is in the category with nuts or seeds.

A nurse is monitoring a newly hired unlicensed assistive personnel (UAP) perform a bed bath on a client needing total care. Which action by the UAP would require further teaching? Select all that apply 1. Lowers side rails on both sides of bed. 2. Washes eyes with mild soap and water from the inner to outer canthus. 3. Makes certain bath water temperature is between 110-115°F (43-46°C). 4. Uses long, firm strokes to wash from wrist to shoulder of each arm. 5. Performs a back massage after completing the bath.

1., & 2. Correct: The nurse needs to intervene in these situations. Both side rails should not be lowered because the client could fall out of the bed. The UAP should lower the side rail closest to themselves and keep the opposite rail up. Wash eyes with water only since soap is very irritating to the eyes. 3. Incorrect: This would be a correct action by the UAP. The nurse does not need to intervene. Temperatures less than 110°F (43°C) can chill the client, and a temperature greater than 115°F (46°C) may be too hot and burn the client. 4. Incorrect: This is a correct action and does not require intervention by the nurse. Firm strokes from distal to proximal areas promote circulation by increasing venous blood return. 5. Incorrect: A back massage is appropriate after a bath and does not require nursing intervention. A back massage is a way of providing relaxation for the client.

The community health nurse is planning to teach nutritional education to a group of adults attending a health fair. What tips about health eating should the nurse include? Select all that apply 1. Pay attention to fullness cues during meals. 2. Make one fourth of the plate fruits and vegetables. 3. Drink sweet tea rather than soft drinks with meals. 4. Eat foods low in dietary fiber. 5. Consume less than 30% of calories from saturated fatty acids. 6. Use a smaller plate for meals.

1., & 6. Correct: Pay attention to hunger and fullness cues before, during, and after meals. Use them to recognize when to eat and when you have had enough. Portion out foods before eating. A smaller plate will make the amount of food look larger. 2. Incorrect: Make half the plate fruits and vegetables. 3. Incorrect: Cut calories by drinking water or unsweetened beverages rather than drinks with sugar, such as soft drinks and sweet tea. 4. Incorrect: Diets should be high in fiber coming from fruits, vegetables, and whole grains. 5. Incorrect: Individuals should consume less than 10% of calories from saturated fatty acids (approximately 20 grams of saturated fat per day in a 2000 calorie diet).

The nurse is observing a new nurse inserting a nasogastric (NG) tube. Which action by the student nurse needs to be corrected by the nurse? Select all that apply 1. Measures from the tip of the nose to the xiphoid process of the client. 2. Lubricates the NG tube with petroleum gel. 3. Aspirates the NG tube to test gastric contents with a pH stip. 4. Marks the tubing at measurement mark with tape and secures to nose. 5. Places tube end into a glass of water to assess for bubbling.

1., 2., & 5. Correct: These actions by the new nurse are not done properly. The measurement for tube placement should be nose to ear and then xiphoid process. Lubricate the tube with a water solution, not a petroleum gel. Never place the tube in water because if the tube is in the trachea, the client can aspirate the water into the lungs. 3. Incorrect: This is the proper technique for checking placement of the NG tube. The pH should be less than 5 if in the stomach. 4. Incorrect: Yes, the tubing should be marked with a piece of tape and secured to the nose with tape or a commercial device if available.

A nurse working in a clinic is planning to assess a client for any sensory deficits. What assessments should the nurse include? Select all that apply 1. Ask the client about any recent changes in vision. 2. Observe the client's conversation with others. 3. Assess two-point discrimination. 4. Perform the Rinne test. 5. Test near vision with the Snellen chart.

1., 2., 3., & 4. Correct: Physical assessment determines whether the senses are impaired. During the physical examination, the nurse assesses vision and hearing and the olfactory, gustatory, tactile, and kinesthetic senses. The exam should reveal the client's specific visual and hearing abilities, perception of heat, cold, light touch, pain in the limbs, and awareness of the position of body parts. Start with a history and ask about recent changes in vision. Observing client conversation with others can indicate hearing or communication problems. Two-point discrimination will assess tactile sense. The Rinne test assesses hearing. 5. Incorrect. Near vision is assessed by using the Rosenbaum eye chart. It consists of paragraphs of text or characters in different sizes on a 3.5 x 6.5 inch card. Be sure the client has a literacy appropriate for the text used.

A school nurse is planning to teach kindergarten students about oral health. Which points should the nurse include? Select all that apply 1. Do not drink soft drinks between meals. 2. Eat raw vegetables to help keep teeth clean. 3. Brush teeth twice a day with toothpaste that does not have fluoride. 4. Use a pea size amount of toothpaste. 5. Floss teeth daily.

1., 2., 4., & 5. Correct: Avoid sweet foods and drinks between meals. Take them in moderation at meals. Eat coarse, fibrous foods, cleansing foods, such as fresh fruits and raw vegetables. If unable to brush after a meal, vigorously rinse mouth with water. Teeth should be flossed daily. 3. Incorrect: Brush the teeth thoroughly with toothpaste that has fluoride.

What signs and symptoms will the nurse look for when caring for an infant with severe dehydration? Select all that apply 1. Dark, yellow urine 2. Lethargic 3. Bulging fontanels 4. Tachypnea 5. Decreased urine output

1., 2., 4., & 5. Correct: These would be signs and symptoms of dehydration in an infant. Amber or dark urine is an indication of dehydration. Urine should be a clear, pale yellow. Fussiness and irritability are seen in infants when they do not feel well. As dehydration worsens, lethargy and unresponsiveness can develop. Tachypnea or rapid respiration along with tachycardia and low blood pressure are present with severe dehydration. With severe dehydration, there will be decreased urine output. The body is trying to conserve volume. 3. Incorrect: The fontanels will be sunken rather than bulging. Bulging fontanels indicate brain swelling or fluid build up in the brain. Sunken fontanels are related to dehydration.

A client who is at high risk for developing a stroke has been advised to follow a Mediterranean type diet by the primary healthcare provider. Which food choices, if selected by the client, would indicate to the nurse that the client understands this diet. Select all that apply 1. Grilled eggplant 2. Purple grape juice 3. Bacon 4. Cashews 5. Skim milk 6. Salmon

1., 2., 4., 5., & 6. Correct: It is reasonable to counsel clients to follow a Mediterranean-type diet over a low-fat diet. The Mediterranean type diet emphasizes vegetables, fruits, and whole grains and includes low fat dairy products, poultry, fish, legumes, and nuts. It limits intake of sweets and red meats. 3. Incorrect: Substitute fish and poultry for red meat. When eaten, make sure it's lean and keep portions small (about the size of a deck of cards). Also avoid sausage, bacon and other high-fat meats.

What should the nurse check when assessing a client's balance? Select all that apply 1. Walking on tiptoes 2. Babinski reflex 3. Romberg test 4. Muscle strength of legs 5. Dorsalis pedis pulses

1., 3., & 4. Correct: Asking the client to walk on the tips of the toes assesses foot strength and balance. Muscle strength is needed to maintain balance and a Romberg's test asks the client to stand erect with arms at their side and feet together. The nurse notes any sway or unsteadiness. Then the client does the same thing with their eyes closed for 20 seconds again noting imbalance and sway. A positive Romberg is seen with swaying and moving feet apart to prevent a fall. It indicates a problem with balance. 2. Incorrect: Babinski sign is an important neurologic examination based upon what the big toe does when the sole of the foot is stimulated. If the big toe goes up, that may mean trouble with the central nervous system. This is not part of assessment for balance. 5. Incorrect: Assessing the dorsalis pedis pulse is done as part of a circulatory check not while assessing balance.

Which discharge instruction should the nurse implement for a client diagnosed with insomnia? Select all that apply 1. Eliminate chocolate in the evening. 2. Drink a glass of red wine 1 hour prior to bedtime. 3. Perform progressive relaxation techniques at bedtime. 4. Take acetaminophen/diphenhydramine 2 tablets at bedtime. 5. Leisurely walk 3 hours prior to bedtime. 6. Increase the airflow on the continuous positive airway pressure (CPAP) machine.

1., 3., & 5. Correct: Consuming chocolate in the evening may cause insomnia. Chocolate contains caffeine and xanthines which are stimulates. The chemicals will suppress melatonin and increase the time to fall asleep. Progressive relaxation techniques are recommended to reduce insomnia. This exercise is a systematic relaxation and tensing of the muscle groups of the body. Insomnia is reduced by increasing muscle relaxation and decreasing the stress level of the client. Non Strenuous exercises such as a leisure walk performed within 3 hours of bedtime promotes the reduction of the client's stress level. 2. Incorrect: Consuming alcohol prior to bedtime is not recommended. Alcohol consumption increases the start of sleep but reduces rapid eye movement (REM) sleep. The side effect of the alcohol may also cause the client to awaken during night and have difficulty returning to sleep. 4. Incorrect: Diphenhydramine is not recommended for insomnia. The action of the diphenhydramine may cause the client to feel drowsy but provides only temporary increase in quantity of sleep. The hypnotic effect of diphenhydramine will cause client to experience decrease energy levels the next morning. 6. Incorrect: A CPAP is prescribed for a client with obstructive sleep apnea not insomnia. The CPAP machine delivers a constant air pressure to the lungs. The constant air flow will keep the airway open during sleep.

A nurse is teaching a client who has frequent urinary tract infections how to prevent future infections. What statement by the client would indicate to the nurse that treatment has been successful? Select all that apply 1. "I will go to the bathroom as soon as the urge to void hits me." 2. "It is important for me to drink five to six 8 ounce glasses of water every day." 3. "I should eat foods such as plums and prunes to increase the acidity of my urine." 4. "Nylon underwear should be worn when I am free from infection." 5. "When I clean after voiding, I will discard toilet paper after each swipe."

1., 3., & 5. Correct: Holding urine can lead to stasis of urine and increasing the risk for infection. Foods such as eggs, cheese, meat and poultry, whole grains, cranberries, plums and prunes, and tomatoes tend to increase the acidity of urine. Acidic urine is less likely to allow for bacterial growth. Discarding toilet paper after each swipe will decrease exposure and accidental introduction of bacteria into the urinary meatus. 2. Incorrect: Emphasize the importance of drinking eight to ten 8 ounce glasses per day. Water helps flush bacteria from the urinary tract. 4. Incorrect: Cotton underwear is recommended. The natural fibers work to wick moisture away from the skin which discourages yeast growth.

An unconscious client is admitted to the ICU with a closed head injury suffered in a fall. Despite aggressive efforts, the client expired within 24 hours. The nurse must complete postmortem care while awaiting the coroner. The nurse knows what action is not appropriate in this situation? Select all that apply 1. Remove indwelling catheter 2. Disconnect the ET tube from ventilator 3. Remove hospital ID band 4. Cap all intravenous lines 5. Wash body head to toe

1., 3., & 5.CORRECT. The client expired of injuries within 24 hours of being admitted to the hospital, which requires investigation by a coroner. It must be determined if death resulted from fall injuries, or whether any action, or lack thereof, by medical personnel contributed to the client's demise. When completing postmortem care on a "coroner's case," the nurse must leave all invasive lines and tubes in place for investigative purposes. Therefore, it would not be appropriate for the nurse to remove the foley catheter, although the urine can be emptied from the bag. It is also incorrect to remove any hospital identification bands. Washing the body should never be done since evidence could be disturbed or even removed. 2. INCORRECT. This action is acceptable since the client would not be transported while still attached to a ventilator. However, the endotracheal tube itself must remain taped in place when the client is transported to the coroner's facility. 4. INCORRECT. It is not necessary to leave the IV bags attached to intravenous catheters. The tubing and bags may be removed as long as the intravenous catheter itself remains intact on the client. Any variation of this standard procedure would be determined by the facility or coroner in advance.

A hospitalized client reports needing scented candles to aid sleep. The nurse informs client lit candles are not permitted in the facility. What appropriate alternatives could the nurse suggest to the client to assist with the sleep process? Select all that apply 1. Use an electric potpourri burner. 2. Place dry potpourri in nightstand. 3. Bring in live flowers to keep in room. 4. Spray scented air freshener frequently. 5. Dab scented oil on corner of the sheets.

2 and 5. CORRECT: The nurse must provide the client with alternatives methods to aid sleep that do not present a safety hazard. Potpourri is fragrant dried flowers or plant stems which emit a smell based on the assortment. Sprinkling a small amount inside the nightstand drawer would allow the scent to gently permeate the area next to the client's bed without presenting a safety hazard and the aroma would be consistent over long periods of time. Also, a tiny drop of an essential oil dabbed on the corner of the pillow case or sheet would also provide the client with desired needed sleep enhancement without impacting health or safety issues. 1. INCORRECT: Hospitals have specific regulations about outside electronics, requiring most to be checked by maintenance staff prior to use in the facility. An electric potpourri burner melts scented wax in a small open ceramic dish, providing odor as it dissipates. An open container of hot wax plus the need to keep the burner plugged in all night are extreme safety hazards to client and staff. 3. INCORRECT: This inefficient and costly method to aid client sleep is impractical on several levels. The fragrance of flowers rapidly fades, based on ambient temperature and room size. Additionally, the inconsistency of smell would not provide the same restful level of sleep during the night. 4. INCORRECT: Spraying non-hospital approved air freshener could prove problematic for other clients, since that odor would not be confined to just the client's room. Secondly, the quick dissipation of the spray would not provide an entire night of restful sleep.

The nurse is discussing foot care with a client who was recently diagnosed with diabetes. Which statement by the client indicates an understanding of foot care? 1. "I will soak my feet for 30 minutes a day." 2. "I will avoid using a heating pad on my feet." 3. "I can use scissors to remove the corns on my toes." 4. "I enjoy walking without my shoes around the house."

2. Correct: One of the long-term complications of diabetes is peripheral neuropathy. As the neuropathy progresses the feet have reduced sensation and may eventually become numb. The client should avoid using heating pads and hot water bottles. Due to the decrease sensation of the feet, the client is in danger of blistering and burning the feet. 1. Incorrect: A complication of diabetes is an increased risk of foot infections. The client is immunocompromised which impairs the leukocytes that destroy bacteria. The client should not allow moisture to accumulate between the toes. 3. Incorrect: Due to the possibility of the client experiencing peripheral neuropathy, the client should not remove any corns from their toes. If a cut occurs while removing the corn, the client is a risk for an ulcer developing. A primary healthcare provider should prescribe the appropriate treatment for corns. 4. Incorrect: Walking without appropriate shoes is dangerous for the client diagnosed with diabetic peripheral neuropathy. After stepping on an object, the client cannot feel the damage to the skin which could result in a scratch or cut.

The nurse enters a client's room to administer morning medications and notes that the client is praying aloud. What would be the nurse's best action? 1. Interrupt the client to administer the medications. 2. Wait quietly until the prayer is finished. 3. Join the client for the prayer. 4. Ask the client if you can provide a directed prayer.

2. Correct: This is the best action by the nurse as this is a private spiritual moment for the client. Prayer is a self-care strategy that provides comfort, increases hope, and promotes healing and psychological well-being. The nurse could either leave and return later or wait quietly for the client to finish. 1. Incorrect: Administering the medications can wait until the client finishes the prayer. 3. Incorrect: Do not assume that the client wants others to join in the prayer. This is a private moment for the client. 4. Incorrect: Do not assume that the client wants others to join in the prayer. Don't interrupt the client while praying.

What dietary information should the nurse provide to a client diagnosed with Celiac disease? Select all that apply 1. "The most cost effective way to follow the lactose free diet is to eat more fruits and vegetables." 2. "Creamed based canned soups are a source of hidden wheat." 3. "You can eat foods containing fax, corn, or rice." 4. "Avoid foods and beverages that contain malt." 5. "Do not eat traditional wheat products such as pasta."

2., 3., 4., & 5. Correct: Soups and sauces are one of the biggest sources of hidden gluten, as many companies use wheat as a thickener. It is always a good idea to read the label of any pre-prepared or canned soups and sauces, paying special attention to those that are cream based. Grains that are naturally gluten free include rice, corn, potato, quinoa, kasha, flax, and nut flours. Malt flavoring or extract, which contains gluten may be found in cornflakes and puffed rice cereal. It is also found in beers, ales, and malt vinegars. As a rule, traditional wheat products such as pastas, breads, crackers, and other baked goods are not gluten-free. However, there are many gluten-free options available that use alternative flours and grains. 1. Incorrect: The client who has Celiac disease is prescribed a gluten free diet rather than a lactose free diet.

A nurse is caring for client with a left above the knee amputation 48 hours postop. The client is experiencing left lower leg pain on a scale of 6 out of 10. Which pain relief intervention would the nurse implement? 1. Position the client in a supine position. 2. Rewrap the ace bandage on the stump. 3. Instruct the client in guided imagery techniques. 4. Initiate range of motion exercises to the knee.

3. Correct: Phantom limb pain (PLP) may be experienced in the amputated part after surgery. The client may describe the PLP as crushing, cramping, and burning. Complementary therapy is a non-pharmacological comfort measure that can be utilized to reduce the client's PLP. Instructing the client to implement guided imagery techniques will assist the client in reducing PLP. 1. Incorrect: Placing the client in various positions in bed by the nurse will not reduce the client's PLP. The client's PLP can be addressed with complementary therapy and medications such as calcitonin, beta-blockers, antiepileptics, antispasmodics or antidepressant medications. 2 Incorrect: Rewrapping the ace bandage on the stump by the nurse will not reduce the phantom limb pain. Wrapping the stump will decrease edema, secure the dressing, and assist in shrinking the limb. 4. Incorrect: Range of motion exercises will decrease the possibility of flexion contractures of the hip and knee. The improved flexion of the hip and knee with range of motion will not decrease PLP.

A nurse is feeding a client diagnosed with a stroke who is exhibiting dysphagia. Which action by the nurse would be appropriate? 1. Elevate the head of the bed to 15 degrees. 2. Request the client to not hold food in their mouth. 3. Monitor for frequent throat clearing after eating. 4. Orient the client to the location of food on their plate.

3. Correct: When helping to feed a client with dysphagia, the nurse should monitor for signs of aspiration such as frequent throat clearing during and after meals. The client is trying to move the bolus of food down esophagus. Aspiration is a condition where food, liquids or saliva moves into the lungs instead of the esophagus during eating. 1. Incorrect: The client should be sitting upright or a high-fowler's position. This position allows for more flexibility of neck movement to promote swallowing. The nurse can keep the client's neck in the neutral position or their chin lowered to their chest. 2. Incorrect: Why is the client holding food in their mouth? Are they disoriented or with a cognitive impairment? Asking a client who is disoriented or with a cognitive impairment to not hold food in their mouth is not an effective intervention. 4. Incorrect: Does the location of the food on the plate affect how a client swallows the food. The location of the food will not affect the possibility of the client aspirating during swallowing food.

The nurse is performing sterile wound care for partial thickness burns on a client's lower right leg. Prior to initiating this procedure, what action should the nurse complete first? 1. Position client upright with right leg elevated. 2. Obtain wound culture before cleaning wound. 3. Assess current pain level and medicate. 4. Encourage client to verbalize concerns.

3. Correct: Wound care on burns is a painful process, particularly with partial thickness burns (formerly referred to as second degree) because nerve endings are intact and exposed. Pre-medicating is a priority action, since pain medication can take up to 30 minutes to activate within the body. Clients are more cooperative and heal faster when pain is well controlled. 1. Incorrect: Proper visualization during wound care is vital, as is client comfort during the procedure. However, completion of this process does not require the client to be in an upright position. In fact, that may be counter productive at this time. Additionally, whether the right leg needs elevated depends on the size or location of the burn on the right leg, and that information has not been provided in the question. 2. Incorrect: While it is true that any wound culture must be obtained prior to cleaning the affected area, this action is not presently the nurse's first priority. Consider the nursing process and choose another option. 4. Incorrect: Therapeutic communication is an ongoing process during any client interaction, particularly when the nurse needs to explain an upcoming procedure. Allowing the client to express fears, verbalize concerns or ask questions enhances cooperation. Although this exchange of information is occurring throughout this period of time, the nurse has another priority action that should be completed first.

The nurse is evaluating an elderly bedridden client for possible fecal impaction. What sign/symptom should the nurse report as most indicative for a fecal impaction? 1. Rigid, board-like abdomen 2. Absence of any bowel sounds 3. Diarrhea with severe cramping 4. Constipation with liquid seepage

4. CORRECT. A client may have several symptoms with a fecal impaction; however, the most classic symptom which the nurse should report is the presence of constipation in the presence of liquid fecal seepage from the rectum. The client may also report abdominal distention with a feeling of fullness, cramping or even painful defecation. 1. INCORRECT. Although the client may report abdominal pain, a rigid, board-like abdomen is indicative of peritoneal inflammation such as peritonitis. As pain increase, the abdominal muscles respond by becoming rigid, hence giving the board-like appearance. 2. INCORRECT. A complete absence of bowel sounds is indicative of other bowel issues, such as a paralytic ileus, which occurs when peristalsis has completely stopped. That is not the case with an impaction. 3. INCORRECT. Diarrhea, especially with cramping, may be attributed to a variety of illnesses, including gastroenteritis, Crohn's disease or even ulcerative colitis. Additionally, diarrhea is not the same as liquid seepage.

A client with a history of deep vein thrombosis (DVTs) is being instructed on how to apply compression stockings prior to discharge. What statement alerts the nurse the client may be noncompliant when at home? 1. "I will follow the special diet in order to lose weight." 2. "I should walk a little every few hours after sitting." 3. "My husband can help remind me not to cross my legs." 4. "The stockings are too difficult to put on every morning."

4. CORRECT: Compression stockings are used to prevent the formation of blood clots, reduce the diameter of distended veins and decrease stasis. Usually these stockings are ordered to be applied upon rising in the morning and removed at night, depending on the disease process. The client's comment suggests the difficulty of putting the hose on may lead to not wearing the stockings consistently. 1. INCORRECT: This statement by the client indicates a positive attitude about the need to lose weight and the intention of following the prescribed diet. Obesity is one of several main factors that can lead to the development of DVTs. 2. INCORRECT: Prolonged sitting, or even lying down, can increase the incidence of blood clots or DVTs. If the client does a lot of sitting during the day, it is advisable to walk around every few hours to reduce stasis. The client is acknowledging the need to increase mobility regularly, which is an indication of compliance. 3. INCORRECT: Placing pressure directly on vessels by crossing the legs compresses both veins and arteries, thus increasing the potential for blood clots or dislodging an unknown clot. The client has acknowledged the need to keep legs uncrossed and the benefit of having family provide reminders.

The nurse is talking to the parent of a 3 year old child who was constipated 1 week earlier. The child is on a regular diet. What statement by the parent indicates to the nurse that the prescribed treatment for constipation has been effective? 1. "My child drinks 1000 mL of fluids daily." 2. "My child is eating more fruit every day." 3. "I administered the prescribed oil-retention enema 6 days ago to my child." 4. "My child has had a soft, formed, brown stool every day for 6 days without straining."

4. Correct: A client is assessed as constipated when they have hard stools, difficulty passing the stool, and incomplete passage of stool. The desired outcome of constipation therapy is for the child to have soft, formed, bowel movements. The mother states that the child has had soft, formed, brown stools every day for the last 6 days. 1. Incorrect: Can you evaluate the effectiveness of the treatment plan by the parent describing how much fluid the child consumes in 24 hours? No. This is an action based on the need to increase the fluid intake to help decrease constipation. This is not an evaluation of the prescribed treatment for constipation. 2. Incorrect: This statement is a description of the classification of food that the child is eating. The effectiveness of the prescribed plan for the constipation is not addressed. 3. Incorrect: The mother is describing the completion of a prescribed treatment. The results of the enema are not listed, and it does not evaluate the prescribed treatment for constipation.

The hospice nurse has been assigned a new client who is being cared for at home by family members. Based upon the client's physical assessment, the nurse is aware that the client's death is imminent. What is the nurse's most important role in the care of the family at this time? 1. Providing care for the client, allowing the family to rest. 2. Providing education regarding the symptoms the client will likely experience. 3. Allowing the family to express their feelings and actively listening. 4. Communicating the client's impending death to the family while they are together.

4. Correct: Communicating news of the client's impending death to the family while they are together. The nurse's most important role in the care of the family is compassionate communication. The family needs to be informed about the situation so that they are prepared for the client's death and can provide support to one another. 1. Incorrect: Providing respite time when death is imminent is not a priority. Family should be allowed to spend time with the client. They will, more than likely, want to be with the client in the last hours. 2. Incorrect: When death is imminent, education of what to expect is appropriate, but does not take priority over compassionate communication. Compassionate communication is most important at this time. 3. Incorrect: Silence and listening sends a message of acceptance and comfort. Although important, allowing for expression of feelings is not more important than preparing the client for the imminent death.

How does the nurse identify the correct size of crutches for a client? 1. Turn the crutches upside down and measure from the heel to the shoulder. 2. Obtain a set of crutches and adjust the height until the client can stand comfortably while resting the axilla on the crutch pad. 3. Measure the client while standing upright from the axilla to the heel then adjust the crutches so that the elbow flexion is a 30-degree angle. 4. Measure the client from 2 inches below the axilla to 6 inches lateral to the client's heel.

4. Correct: Measuring the client from 2 inches below the axilla to 6 inches lateral to the client's heel correctly measures a client for crutches. This is the correct size while a client is standing. 1. Incorrect: This is not the correct way to choose the correct size crutches. Without the proper fit safety is a concern. 2. Incorrect: This is not how to choose the correct size of crutches. The client should not rest their weight on the crutch pad as this can cause damage to the brachial plexus nerve. 3. Incorrect: This is not how to choose the correct size of crutches. The shoulders should be relaxed, the hand piece should be adjusted to provide a 20°- 30° elbow flexion. The 2 inch drop below the axilla allows the weight to be pressed against the sides and the hands absorb the weight. The crutch should not be placed against the axilla or the brachial plexus nerve could be damaged.