The client ambulates with two axillary crutches and the nurse notes that the client's weight is resting on the axilla. Which should the nurse do to prevent client injury?
1. Document that the client is uses the crutches properly.
2. Encourage client to minimize the weight on the axilla.
3. Fit the client for crutches while the client wears shoes.
4. Increase the layer of padding to the top of the crutches.
3
3. The crutches may be too long for the client or the client may be barefoot, so the best action for the nurse is to measure the client again for crutches with shoes on both feet to prevent radial nerve damage at the axilla and to instruct the client to wear shoes when using the crutches.
1. The nurse cannot document that the client is using the crutches properly because proper use of crutches does not include axillary pressure of any kind.
2. The nurse instructs the client to avoid all pressure on the axilla.
4. The nurse aggravates the problem of axillary pressure by increasing the axillary padding because it increases the height of the crutches.
You might also like to view...
The nurse caring for a client admitted with septic shock is aware of the need to assess for the development of acute respiratory distress syndrome (ARDS). Which early clinical manifestation would indicate the development of ARDS?
A) Intercostal retractions B) Cyanosis C) Tachypnea D) Tachycardia
According to the U.S. Department of Labor, occupation-related musculoskeletal disorders are illnesses or injuries of what? (Mark all that apply.)
A) Nerves B) Cartilage C) Tendons D) Arteries E) Veins
A nurse is providing teaching for a patient who
will be taking varenicline (Chantix) as part of a smoking-cessation program. Which teaching points are appropriate for a patient taking this medication? (Select all that apply.) a. This drug is available as a chewing gum that can be taken to reduce cravings. b. Use caution when driving because drowsiness may be a problem. c. There have been very few adverse effects reported for this drug. d. Notify the prescriber immediately if feelings of sadness or thoughts of suicide occur. e. Avoid caffeine while on this drug.
A patient has recently begun taking phenytoin (Dilantin) for a seizure disorder. The nurse notes a reddish-brown color to the patient's urine. Which action will the nurse take?
a. Ask the provider to order a serum drug level. b. Reassure the patient that this is a harmless side effect. c. Report possible thrombocytopenia to the provider. d. Request an order for a urinalysis and creatinine clearance.