a nurse is teaching a client about the use of crutches which of the following instructions should the nurse include
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PN ATI Capstone Proctored Comprehensive Assessment B Quizlet

1. A client is being taught how to use crutches by a nurse. Which of the following instructions should the nurse include?

Correct answer: C

Rationale: The correct answer is C: 'Support your weight on your hands.' When using crutches, it is important to support your weight on your hands rather than underarms to prevent injury to the axillary nerves and blood vessels. Placing weight on the underarms can lead to nerve damage and circulatory issues. Choices A, B, and D are incorrect. Keeping the elbows extended when walking is important for stability, holding the crutches slightly in front of you allows for proper balance, and supporting weight on the hands maintains the correct weight-bearing position.

2. When teaching about safety risks for adolescents, what should be included?

Correct answer: B

Rationale: When educating about safety risks for adolescents, it is crucial to address the impact of peer influence on engaging in high-risk behaviors, which can result in injuries. Choice A is incorrect because adolescents are known to sometimes take risks and not always follow rules. Choice C is incorrect as injuries among adolescents can also happen outside of sports activities. Choice D is incorrect as adolescents may not always be fully aware of the dangers of substance use.

3. A client at 38 weeks gestation with a history of herpes simplex virus 2 is being admitted. Which of the following questions is most appropriate to ask the client?

Correct answer: B

Rationale: The most appropriate question to ask a client with a history of herpes simplex virus 2 at 38 weeks gestation is whether they have any active lesions. Active herpes lesions during labor can necessitate a cesarean delivery to prevent neonatal transmission. Asking about ruptured membranes (choice A), beta strep status (choice C), or contraction timing (choice D) is important but not the priority when managing a client with a history of herpes simplex virus 2 due to the high risk of neonatal transmission.

4. A nurse is admitting a client who has suspected appendicitis. Which of the following findings should the nurse report to the provider immediately?

Correct answer: A

Rationale: A distended, board-like abdomen is a concerning sign indicating the possibility of a ruptured appendix and peritonitis, which are medical emergencies. Reporting this finding immediately is crucial for prompt intervention. Choice B, an elevated WBC count, could indicate infection but is not as urgent as the risk of a ruptured appendix. Choice C, rebound tenderness over McBurney’s point, is a classic sign of appendicitis but does not indicate an immediate threat like a possible rupture. Choice D, a slightly elevated temperature, is a nonspecific finding and not as critical as the risk of peritonitis associated with a distended, board-like abdomen.

5. A nurse is preparing to administer a blood transfusion. Which of the following actions should the nurse take first?

Correct answer: B

Rationale: The correct first action the nurse should take when preparing to administer a blood transfusion is to verify the blood type and crossmatch. This step is crucial to ensure compatibility and prevent transfusion reactions. Obtaining the client's consent is important but should follow the verification process. Taking baseline vital signs is necessary before starting the transfusion, but confirming compatibility takes precedence. Priming the IV with normal saline is a step done before starting the transfusion, after ensuring blood compatibility.

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