after instructing the client on crutch walking technique the nurse should evaluate the clients understanding by using which of the following methods

NCLEX-RN

NCLEX RN Predictor Exam

1. After instructing the client on crutch walking technique, the nurse should evaluate the client's understanding by using which of the following methods?

A. Return demonstration
B. Explanation
C. Achievement of 90 on written test
D. Have the client explain the procedure to the family

Correct answer: A

Rationale: After teaching the client on crutch walking technique, assessing the client's understanding is crucial. The most effective method to evaluate the client's comprehension of a hands-on skill like crutch walking technique is through a return demonstration. This allows the nurse to observe the client performing the technique, ensuring they have grasped the instructions correctly and can execute the skill safely. While providing an explanation can help clarify doubts, it may not confirm the client's ability to perform the skill. Achieving a high score on a written test assesses cognitive understanding but not necessarily the practical application of the skill. Having the client explain the procedure to the family does not directly assess their ability to perform the skill themselves; it tests their ability to communicate the information to others.

2. Which of these guidelines would a healthcare professional follow when measuring a patient's weight?

A. The patient is always weighed wearing only undergarments.
B. The type of scale matters and should be consistent day to day.
C. The patient should remove heavy outer clothing, shoes, and jackets before weighing.
D. Attempts should be made to weigh the patient at approximately the same time of day if a sequence of weights is necessary.

Correct answer: D

Rationale: When measuring a patient's weight, it is important to ensure accuracy and consistency. If a sequence of repeated weights is necessary, the healthcare professional should attempt to weigh the patient at the same time of day and with the same types of clothing worn each time. It is crucial to use a standardized balance or electronic standing scale for accurate weight measurement. Choice A is incorrect as patients should remove heavy outer clothing, shoes, and jackets before being weighed for accurate results. Choice B is incorrect because the type of scale used does matter and should be consistent for reliable weight tracking. Choice C is incorrect as patients should not leave on heavy outer clothing, shoes, or jackets as these items can add to the weight recorded inaccurately.

3. Which of the following is an anthropometric measurement?

A. Blood pressure
B. Temperature
C. Pulse Rate
D. Weight

Correct answer: D

Rationale: Anthropometric measurements relate to the size, weight, and proportions of the human body. Weight is a key anthropometric measurement as it directly reflects body mass, making it the correct choice. Blood pressure, temperature, and pulse rate are physiological measurements that do not specifically pertain to body size or proportion, hence making them incorrect choices in the context of anthropometric measurements.

4. The nurse is taking an initial blood pressure reading on a 72-year-old patient with documented hypertension. How should the nurse proceed?

A. Cuff should be placed on the patient's arm and inflated 30 mm Hg above the point at which the palpated pulse disappears.
B. Cuff should be inflated to 200 mm Hg in an attempt to obtain the most accurate systolic reading.
C. Cuff should be inflated 30 mm Hg above the patient's pulse rate.
D. After confirming the patient's previous blood pressure readings, the cuff should be inflated 30 mm Hg above the highest systolic reading recorded.

Correct answer: C

Rationale: When measuring blood pressure, it's important to account for the possibility of an auscultatory gap, which occurs in about 5% of individuals, particularly those with hypertension due to a noncompliant arterial system. To detect an auscultatory gap, the cuff should be inflated 20 to 30 mm Hg beyond the point at which the palpated pulse disappears. This ensures an accurate measurement of blood pressure by overcoming the potential gap in sounds. Choice A is correct as it follows this guideline. Choices B and C are incorrect because inflating the cuff to 200 mm Hg or above the patient's pulse rate does not address the specific issue of an auscultatory gap. Choice D is incorrect as it focuses on the patient's previous readings rather than the current measurement technique needed to detect an auscultatory gap.

5. When a patient is standing in anatomical position, where are their feet?

A. Facing forward with the toes spread open
B. Facing out to the sides to open the hips
C. Side by side and facing forward; toes resting comfortably
D. The feet are pointed inward.

Correct answer: B

Rationale: When a person is standing in anatomical position, their feet are side by side, and they are facing forward with the toes pointing out to the sides to open the hips. This position allows for proper alignment of the body for anatomical reference. Choice A is incorrect because the feet should not be spread open, but rather side by side. Choice C is incorrect as it does not mention the correct positioning of the feet. Choice D is incorrect as the feet should not be pointed inward, but rather facing out to the sides to open the hips.