the nurse has the client move both crutches forward with weight on the unaffected leg and move the unaffected leg forward shifting weight onto the una
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Nursing Elites

ATI RN

Multi Dimensional Care | Final Exam

1. The client moves both crutches forward, with weight on the unaffected leg, and then moves the unaffected leg forward, shifting weight onto it. Which of the following gaits is being utilized?

Correct answer: B

Rationale: The correct answer is B, Three-point gait. In a three-point gait, one leg is non-weight bearing, as described in the scenario where the client shifts weight onto the unaffected leg. Choices A, C, and D are incorrect. A two-point gait involves partial weight-bearing on both legs, a four-point gait involves weight-bearing on both legs, and 'Unaffected gait' is not a recognized term in gait patterns.

2. The nurse assesses a deep wound. The area is covered by black and necrotic tissue. What term would the nurse use when documenting this wound?

Correct answer: B

Rationale:

3. The nurse is providing education to a client regarding the administration of eye drops. Which of the following actions indicates the need for further client education?

Correct answer: C

Rationale:

4. A client is immobile and requires mechanical ventilation with a tracheostomy. She has a pressure injury on her coccyx measuring 5 cm by 3 cm. the nurse observes bone and tendon at the base of the wound. How would the nurse document this wound?

Correct answer: D

Rationale:

5. What is the priority intervention for the nurse to enhance meeting the psychosocial needs of a client on transmission-based precautions?

Correct answer: B

Rationale:

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