NR-224 Fundamentals – Skills - Set 4 - Part 3

Correct Answer: Assist the client back to a supine position

Dizziness, pallor and diaphoresis on sitting up signal orthostatic hypotension. Lying the client down restores cerebral perfusion immediately and prevents a syncopal fall. Vital signs, causes and a later attempt all come after the client is safe. Option b is incorrect because standing a symptomatic client to obtain a reading is the exact event the nurse is trying to prevent. Positional readings are taken once the client is stable, not while the room is spinning. Option c is incorrect because breathing exercises treat anxiety and atelectasis, not a fall in cerebral perfusion. The problem here is mechanical, caused by pooled venous blood, and only a change in position reverses it quickly. Option d is incorrect because leaving the bedside to arrange equipment abandons a client who is about to faint. A wheelchair may be useful later, but summoning it does nothing for the low pressure causing the symptoms.

Correct Answer: Two or three finger widths separate them

Correct axillary crutch fit leaves roughly two to three finger widths, about one and a half to two inches, between the pad and the axilla. That clearance keeps pressure off the brachial plexus while the hands carry the weight. Option a is incorrect because a pad pressed into the armpit is the precise setup for crutch palsy. Sustained compression of the radial nerve produces numbness, weakness and wrist drop, and crutches fitted this way are almost always too long. Option b is incorrect because one finger width is too little clearance. As soon as the client shifts weight or fatigues, the shoulder drops and that narrow gap closes onto the nerves and vessels running through the axilla. Option d is incorrect because a gap that wide means the crutches are far too short. The client stoops forward to reach the hand grips, the center of gravity moves outside the base of support, and back strain follows.

Correct Answer: The greater trochanter of the femur

With the tip on the floor beside the foot, the top of the cane handle should reach the greater trochanter, which places the elbow in about fifteen to thirty degrees of flexion for shock absorption and push off. Option b is incorrect because a handle set at the rib cage would put the cane far above hip level. The shoulder would be hitched upward, the elbow over flexed, and the trunk pushed toward the unaffected side. Option c is incorrect because the anterior superior iliac spine sits on the front of the pelvis, not at the side where the hand hangs. Fitting to it angles the cane inward and gives a measurement no one can reproduce. Option d is incorrect because the upper arm is not a fixed landmark and shifts with every change in shoulder position. Cane length is verified at the hip or wrist crease, landmarks that hold still when the arm hangs relaxed.

Correct Answer: The pulses, capillary refill and distal sensation

Dusky, cool fingers signal circulatory compromise, and neurovascular status distal to a restraint is the priority assessment because a device applied too tightly causes ischemia and permanent nerve injury within hours. Option a is incorrect because psychological status is assessed at every check, yet it addresses distress rather than the perfusion problem the color change announces. Emotional support follows once the limb is confirmed to be perfused. Option b is incorrect because inspecting for redness looks at the skin surface while the finding described points deeper, to blood flow past the device. Skin checks matter, but they lag behind circulation as an indicator. Option c is incorrect because call light access is part of the environmental setup confirmed when the restraint was applied. Reaching the call light does nothing to reveal whether arterial flow to the hand is obstructed.

Correct Answer: We put carbon monoxide alarms on every level.

Working smoke alarms and carbon monoxide detectors belong on every level of the home, tested monthly with batteries changed at least yearly. A single alarm on one floor leaves the other levels unprotected. Option a is incorrect because one alarm cannot cover a two-story house with a basement wood stove. Detection has to exist on the level where a fire starts, or the warning arrives after the smoke does. Option b is incorrect because alarms are tested every month, not every few years. A detector with a dead battery is indistinguishable from no detector at all, and batteries are replaced at least annually. Option d is incorrect because carbon monoxide has no odor. Waiting for a smell means the couple would never be warned, which is precisely why a detector rather than the nose has to do the sensing.

Correct Answer: Offering fluids and assisting with toileting needs

Offering fluids and assisting with toileting are routine care tasks with predictable outcomes, so they fall within the assistive personnel role. Assessment of circulation, skin and continued need stays with the nurse at every release. Option a is incorrect because examining tissue under a restraint for breakdown, abrasion and pressure change is a nursing assessment. Unlicensed staff can mention what they see, though deciding whether a finding requires removal of the device is beyond them. Option c is incorrect because neurovascular evaluation is the priority nursing assessment during restraint, since a tight device produces ischemia and permanent nerve damage. Interpreting pulses, refill, sensation and motor function cannot be handed to unlicensed staff. Option d is incorrect because discontinuation rests on whether the behavior that justified the restraint has resolved, a judgment reserved for the nurse. Delegating it would place a legal decision about a client's liberty outside nursing.

Correct Answer: In the right hand, on the stronger side

The cane belongs on the strong, unaffected side, opposite the weak leg. From there it advances with the weak leg, widens the base of support and shares the load, which is what unweights the affected hip and knee. Option a is incorrect because a cane held beside the weak leg forces the client to lean over the painful joint. Load on the affected limb rises instead of falling, and lateral balance gets worse rather than better. Option b is incorrect because switching hands destroys the reciprocal pattern the cane is meant to restore. Gait training depends on one consistent sequence, and a hemiparetic client rarely has a usable grip on the affected side. Option d is incorrect because a single cane is a one handed device that widens the base of support to one side. Holding it in front with both hands leaves nothing to steady the client sideways and blocks arm swing.

Correct Answer: Call Poison Help and keep the container handy

Induced vomiting is no longer recommended. The parent calls the Poison Help line immediately, keeps the container in hand so the substance can be identified, and does not induce vomiting unless directed to. Option a is incorrect because ipecac has been withdrawn from routine poisoning care. Vomiting a caustic or a petroleum product a second time burns the esophagus again and adds a real aspiration risk. Option b is incorrect because neither milk nor any home remedy neutralizes an ingested poison. Diluting delays the call that gets the child the right antidote, and it can push a substance further along the gut. Option c is incorrect because waiting for symptoms wastes the window in which treatment works best. Many ingestions look harmless for hours, and the poison center gives advice on the substance rather than on the child's appearance.

Correct Answer: Stop the client and reteach the correct technique

The symptoms describe early crutch palsy from pressure on the brachial plexus and radial nerve. The pressure has to stop now, so the nurse halts the behavior, reteaches weight bearing through the hand grips, and rechecks the crutch length. Option b is incorrect because thicker padding invites the client to lean even harder. Cushioning spreads the force slightly but does not remove it, and the nerve keeps getting compressed every time the client rests on the pads. Option c is incorrect because waiting allows a preventable nerve injury to progress toward wrist drop. Charting is part of the response, but it belongs after the cause has been removed rather than instead of removing it. Option d is incorrect because diagnostic testing addresses a problem whose cause is already visible at the bedside. Crutch palsy is usually a neurapraxia that recovers once the pressure is relieved, so correcting technique comes before any referral.

Correct Answer: Three point gait, crutches with the affected leg

Three point gait is the only pattern that keeps one leg entirely unloaded. Both crutches and the right leg advance together, then the left leg swings through and accepts all the weight, so the fracture never touches the floor. Option a is incorrect because the four point gait requires weight bearing on both legs. It suits bilateral weakness and poor coordination, offering three points of contact at all times, but every cycle loads the injured ankle. Option c is incorrect because pairing a crutch with the opposite foot means both feet strike the floor each cycle. That pattern belongs to a client cleared for partial weight bearing on both legs, which this order specifically forbids. Option d is incorrect because swing through gait moves both legs as a unit past the crutch tips. It was designed for bilateral lower extremity paralysis with braces, and it is the fastest and least stable pattern.