Nclexrn Quiz: Assistive Devices Fit And Safe Use
20 questions · exam conditions
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Assistive Devices Fit And Safe UseQuestion 1 of 20

A 35-year-old client is postoperative after knee surgery and is using crutches with partial weight-bearing. Assessment: the client repeatedly looks down at the crutch tips and loses balance when approaching door thresholds. Which client statement indicates a need for further teaching about their crutches?

"I will look ahead in the direction I'm walking and scan for obstacles."
"I will make sure the rubber tips are dry and not worn before I walk."
"I will use my armpits to support my weight so my hands don't get tired."
"I will move the crutches and my affected leg forward together, then step through with my other leg."
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Nclexrn Quiz: Assistive Devices Fit And Safe Use

Practice Assistive Devices Fit And Safe Use in Nclexrn with focused quiz questions that help you check what you know, review explanations, and build confidence with test-style prompts.

What this quiz covers

This quiz focuses on Assistive Devices Fit And Safe Use, giving you a quick way to practice the rules, question types, and explanations that matter most for Nclexrn.

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Try each quiz question before looking at the correct answer. Use the explanations to review missed ideas, then come back to similar questions until the pattern feels familiar.

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Question 1

A 35-year-old client is postoperative after knee surgery and is using crutches with partial weight-bearing. Assessment: the client repeatedly looks down at the crutch tips and loses balance when approaching door thresholds. Which client statement indicates a need for further teaching about their crutches?

  1. "I will look ahead in the direction I'm walking and scan for obstacles."
  2. "I will make sure the rubber tips are dry and not worn before I walk."
  3. "I will use my armpits to support my weight so my hands don't get tired." (correct answer)
  4. "I will move the crutches and my affected leg forward together, then step through with my other leg."
Explanation: This question tests knowledge of the fit and safe use of assistive devices. Proper fit and safe use of assistive devices are important in nursing practice to maintain balance, avoid obstacles, and support partial weight-bearing postoperatively. Option C indicates a need for further teaching because armpits should not bear weight, risking injury, whereas hands should. Option A promotes safe forward gaze; B ensures tip integrity; D describes correct gait. A transferable principle is to avoid axilla weight-bearing in crutch use. Another principle is to assess visual scanning and balance at thresholds. One strategy for educating clients is to simulate obstacles and provide corrective feedback during practice.

Question 2

A 33-year-old client with a left knee ligament injury is learning to use a cane for weight-bearing as tolerated. The client has good coordination and normal upper-extremity strength but reports feeling "off balance" when turning. What is the most important safety instruction for this client using a cane?

  1. Keep the cane on the side opposite the injured leg and move the cane with the injured leg (correct answer)
  2. Place the cane about 12 inches in front of the body to increase stride length
  3. Use the cane on the injured side to prevent the knee from buckling
  4. Ask the provider to prescribe crutches before practicing turns with the cane
Explanation: This question tests knowledge of the fit and safe use of assistive devices. Proper fit and safe use of assistive devices are crucial in nursing practice to improve balance, reduce fall risk, and support injured limbs during rehabilitation. Option A ensures safe use by placing the cane opposite the injury for optimal support and advancing it with the affected leg. Option B is incorrect as placement should be on the stronger side; C is wrong because using the injured side increases instability; D is less optimal without assessing if crutches are needed. A transferable principle is to teach cane placement on the unaffected side for all unilateral injuries. Another principle is to observe for balance issues during turns and adjust techniques accordingly. One strategy for educating clients is to practice in a controlled environment and gradually increase complexity like turning.

Question 3

An 82-year-old client with chronic heart failure and generalized weakness is being discharged with a standard walker (no wheels). The client has slow gait, needs frequent rest breaks, and has hand strength 3/5 with mild arthritis pain. The nurse should prioritize which assessment finding related to the walker?

  1. The client's elbows flex about 15–30 degrees when holding the walker handgrips while standing upright (correct answer)
  2. The client can climb a full flight of stairs without stopping while using the walker
  3. The client wears supportive shoes when ambulating with the walker
  4. The client requests a provider order for a bedside commode to reduce nighttime walking
Explanation: This question tests knowledge of the fit and safe use of assistive devices. Proper fit and safe use of assistive devices are essential in nursing practice to support weak clients, prevent joint strain, and enhance endurance during ambulation. Option A should be prioritized as it confirms proper walker height, allowing ergonomic elbow flexion and safe weight distribution. Option B is less relevant as stair climbing may not be feasible with weakness; C is important but secondary to fit; D addresses convenience but not directly walker safety. A transferable principle is to assess elbow flexion at 15-30 degrees for all upper-limb assistive devices. Another principle is to evaluate grip strength and pain that may impact device handling. One strategy for educating clients is to provide written instructions with illustrations and review them during follow-up visits.

Question 4

A 22-year-old client with a recent leg injury is using a cane and reports wrist pain after practice. Assessment: the cane is set too high, causing shoulder elevation and minimal elbow flexion. Which action should the nurse take to ensure the device is correctly fitted?

  1. Lower the cane height so the elbow is slightly flexed (about 15–30 degrees) when the client holds the handgrip (correct answer)
  2. Apply a hot pack to the wrist after walking to reduce inflammation
  3. Ask the provider to prescribe a wrist brace before adjusting the cane
  4. Raise the cane height further to shift pressure from the wrist to the shoulder
Explanation: This question tests knowledge of the fit and safe use of assistive devices. Proper fit and safe use of assistive devices are crucial in nursing practice to alleviate pain, correct ergonomic issues, and enhance comfort during rehabilitation. Option A ensures proper fit by lowering the height for elbow flexion, reducing wrist strain from improper positioning. Option B is incorrect as heat doesn't address fit; C is less optimal without adjustments; D is wrong because raising shifts strain elsewhere. A transferable principle is to ensure 15-30 degrees elbow flexion for cane users. Another principle is to monitor for pain as an indicator of poor fit. One strategy for educating clients is to demonstrate height adjustments and confirm relief through trial walks.

Question 5

A 23-year-old client is learning to use crutches after a left ankle fracture and is ordered partial weight-bearing. The client has good upper-body strength but poor coordination when initiating gait. Which action should the nurse take to ensure the crutches are correctly fitted?

  1. Ensure there are about 2–3 finger widths between the axilla and the top of the crutch when standing (correct answer)
  2. Adjust the handgrips so the elbows are fully extended when the client holds the grips
  3. Ask the provider to increase weight-bearing status before fitting the crutches
  4. Set the crutch tips directly under the client's heels to maximize stability
Explanation: This question tests knowledge of the fit and safe use of assistive devices. Proper fit and safe use of assistive devices are essential in nursing practice to prevent nerve compression, improve coordination, and support weight-bearing orders. Option A ensures proper fit by providing space below the axilla, allowing weight on hands and reducing injury risk. Option B is incorrect as full elbow extension reduces shock absorption; C is unnecessary without first fitting properly; D is wrong because tips should be lateral for stability. A transferable principle is to maintain 2-3 finger widths below the axilla for crutch fitting. Another principle is to assess upper-body strength and coordination for gait initiation. One strategy for educating clients is to fit devices in standing position and confirm comfort through trial ambulation.

Question 6

A 47-year-old client is post-operative day 2 after right hip arthroplasty and is using a front-wheeled walker. The client has good upper-extremity strength (5/5) but reports fear of falling; coordination is intact. The nurse observes the client stepping into the walker frame and then pushing it forward while standing inside it. Which client statement indicates a need for further teaching about their walker?

  1. "I will keep the walker close and step to it rather than stepping inside the frame."
  2. "I will push down on the hand grips to help me stand up from the chair."
  3. "I will use the walker to pull myself up by yanking on it while it is in front of me." (correct answer)
  4. "I will look ahead and keep pathways clear of rugs and cords."
Explanation: This question tests the fit and safe use of assistive devices, specifically identifying unsafe walker technique following hip surgery. Safe walker use is essential in nursing practice to protect surgical sites, maintain hip precautions, and prevent falls during post-operative recovery. The correct answer (C) identifies dangerous technique - using the walker to pull oneself up by yanking on it risks tipping the walker backward and violating hip precautions through excessive flexion. Options A, B, and D describe safe practices: proper stepping technique, appropriate use for standing support, and environmental safety awareness. The key principle is that clients should push down on stable surfaces (chair arms) to stand, then position the walker, rather than pulling on the walker itself. When educating post-surgical clients, nurses should demonstrate the safe standing sequence and emphasize protecting the surgical site while building confidence with the assistive device.

Question 7

A 79-year-old client with heart failure and generalized weakness (lower-extremity strength 3/5) is learning to use a standard walker at home after hospitalization. The client's coordination is intact; the client reports dizziness when standing quickly. The nurse observes the client lifting the walker and placing it far ahead before stepping. Which client statement indicates a need for further teaching about their walker?

  1. "I will move the walker a short distance forward and keep all four legs on the floor before I step."
  2. "I will stand up slowly and pause before walking if I feel dizzy."
  3. "I will lift the walker and set it as far forward as I can to take bigger steps." (correct answer)
  4. "I will wear non-skid shoes when I walk with the walker."
Explanation: This question tests the fit and safe use of assistive devices, specifically identifying unsafe walker technique that increases fall risk. Safe walker use is essential in nursing practice to prevent falls, maintain stability, and promote independence in clients with cardiac conditions and weakness. The correct answer (C) identifies unsafe technique - lifting the walker and placing it far ahead encourages overreaching and loss of balance, particularly dangerous for someone with weakness and potential orthostatic changes. Options A, B, and D all describe safe practices: keeping walker legs on the floor, managing orthostatic symptoms, and wearing appropriate footwear. The fundamental principle is that walkers should be advanced a comfortable arm's length (6-8 inches) while maintaining all four legs on the ground for maximum stability. When educating clients, nurses should emphasize "small steps for safety" and practice the proper sequence: advance walker, step with weaker leg, then stronger leg.

Question 8

A 79-year-old client with a history of stroke (mild left-sided weakness, 4/5) is discharged with a quad cane. Assessment: mild left foot drop, slow gait, and fair balance. Which client statement indicates a need for further teaching about their cane?

  1. "I will keep the cane on my right side, since my left leg is weaker."
  2. "I will move the cane forward at the same time as my weaker left leg."
  3. "I will check that all four tips of the quad cane are on the floor before I step."
  4. "I will place most of my body weight through my armpit on the cane when I feel tired." (correct answer)
Explanation: This question tests knowledge of the fit and safe use of assistive devices. Proper fit and safe use of assistive devices are essential in nursing practice to address residual weakness from strokes, improve balance, and prevent compensatory injuries. Option D indicates a need for further teaching because canes do not support weight via armpits, which could imply misuse and risk nerve damage. Option A is correct for side placement; B describes proper advancement; C ensures stability with quad tips. A transferable principle is to clarify that weight goes through hands, not upper body, for canes. Another principle is to assess for foot drop and gait speed. One strategy for educating clients is to correct misconceptions immediately and reinforce with return demonstrations.

Question 9

A 49-year-old client is postoperative day 1 after open reduction and internal fixation of a left tibial fracture and is ordered non–weight-bearing on the left leg. The client has upper-extremity strength 4/5 and becomes short of breath after 10 feet with crutches. Which client statement indicates a need for further teaching about their crutches?

  1. "I will support my weight by pressing down on the handgrips, not by leaning on my armpits."
  2. "I will keep the crutch tips about 6 inches in front and 6 inches to the side of my feet."
  3. "If I feel unsteady, I will rest by letting my armpits bear most of my weight." (correct answer)
  4. "I will look forward while walking and clear throw rugs from my path at home."
Explanation: This question tests knowledge of the fit and safe use of assistive devices. Proper fit and safe use of assistive devices are important in nursing practice to avoid nerve damage, promote effective mobility, and ensure client safety during recovery. Option C indicates a need for further teaching because leaning on armpits can cause brachial plexus injury, whereas weight should be on the hands. Option A is correct technique for weight support; B is proper crutch positioning; D promotes environmental safety and forward gaze. A transferable principle is to verify that clients understand weight should be borne on hands, not axillae, to prevent complications. Another principle is to monitor for signs of fatigue or shortness of breath that could affect crutch use. One strategy for educating clients is to use teach-back methods, asking them to explain and demonstrate safe techniques.

Question 10

A 80-year-old client with chronic obstructive pulmonary disease is discharged with a walker for energy conservation and stability. Assessment: the client becomes dyspneic with exertion and has limited endurance but can follow instructions. Which action should the nurse take to promote safe walker use at home?

  1. Teach the client to sit and rest when short of breath rather than leaning heavily forward on the walker (correct answer)
  2. Teach the client to use the cane on the stronger side when climbing stairs and keep the other hand free
  3. Ask the provider to prescribe supplemental oxygen before the client practices walking with the walker at home
  4. Instruct the client to increase walking speed with the walker to reduce the amount of time spent exercising
Explanation: For a client with COPD, safe walker use includes pacing and stopping to rest when dyspnea occurs. Teaching the client to sit and rest rather than leaning heavily forward on the walker is the correct action because it conserves energy, reduces dyspnea, and prevents the walker from becoming unstable. The cane option is incorrect because it teaches cane technique, not the walker the client was discharged with. The oxygen option is premature unless exercise-related hypoxemia has been assessed; it does not address safe walker technique. The speed option is unsafe because increasing walking speed during exercise increases oxygen demand and may worsen dyspnea and fall risk. Therefore the best action is to teach seated rest and pacing during walker use.

Question 11

A 74-year-old client is being discharged with a walker after hospitalization for pneumonia and deconditioning. Assessment: lower-extremity strength 3/5, slow gait, and needs to rest after 15 feet; the client is alert and follows directions. Which client statement indicates a need for further teaching about their walker?

  1. "I will remove loose rugs and keep pathways clear before I start walking at home."
  2. "I will step into the walker and keep it close rather than reaching far ahead."
  3. "I will use the walker to pull myself up from the bed by yanking on the handgrips." (correct answer)
  4. "I will make sure the rubber tips are not worn and replace them if they start to slip."
Explanation: This question tests knowledge of the fit and safe use of assistive devices. Proper fit and safe use of assistive devices are essential in nursing practice to rebuild strength after deconditioning, prevent fatigue-related falls, and ensure home safety. Option C indicates a need for further teaching because pulling up on the walker can cause tipping, whereas pushing down or using armrests is safer for standing. Option A promotes environmental safety; B describes proper stepping; D ensures non-slip tips. A transferable principle is to avoid using walkers for pulling up to maintain stability. Another principle is to assess endurance and strength for safe distance limits. One strategy for educating clients is to provide checklists for home setup and review them with family members.

Question 12

A 41-year-old client with a left knee injury is using a cane for short distances. Assessment: cane height appears too tall; the client's shoulder on the cane side is elevated and elbow is nearly straight when holding the cane. Which action should the nurse take to ensure the device is correctly fitted?

  1. Lower the cane so the handgrip aligns with the client's wrist crease when standing with arms relaxed (correct answer)
  2. Raise the cane until the handgrip aligns with the client's waist to reduce trunk flexion during gait
  3. Ask the provider to prescribe a walker because the cane height is difficult to adjust and the client needs more support
  4. Add extra padding to the cane handle to compensate for the elevated shoulder posture and reduce pressure on the palm
Explanation: The cane is too tall: the client's shoulder is elevated and the elbow is nearly straight. Correct fit requires lowering the cane so the handgrip is level with the wrist crease when the arm hangs relaxed; this allows about 15–30 degrees of elbow flexion and a neutral shoulder. Raising the cane to the waist would make the handgrip even higher and worsen the elevated shoulder and straight elbow. Asking the provider to prescribe a walker is an unnecessary escalation; the cane height can be adjusted, and the nurse should fit the device before considering a different one. Adding extra padding to the handle does not change the height of the cane, so it cannot correct the shoulder elevation or elbow extension. The nurse's first action is to adjust the cane height using the wrist-crease landmark.

Question 13

A 29-year-old client with a right fibular fracture is using crutches and is ordered non–weight-bearing. Assessment: mild dizziness when standing and difficulty coordinating the crutch sequence. What is the most important safety instruction for this client using crutches?

  1. Use a three-point gait: move both crutches forward, then swing the noninjured leg forward while keeping weight off the injured leg (correct answer)
  2. Keep the crutches tucked under the arms and lean on the axilla pads to reduce hand fatigue
  3. Advance the injured leg first to maintain symmetry during walking
  4. Request a provider order to change the client to weight-bearing as tolerated to reduce fall risk
Explanation: This question tests knowledge of the fit and safe use of assistive devices. Proper fit and safe use of assistive devices are important in nursing practice to enforce weight-bearing restrictions, manage symptoms like dizziness, and promote coordinated mobility. Option A ensures safe use by describing the three-point gait, which keeps weight off the injured leg while maintaining balance. Option B is incorrect as axilla pads should not bear weight; C is wrong because advancing the injured leg first violates NWB; D is less optimal without assessing current needs. A transferable principle is to match gait patterns to weight-bearing status for crutches. Another principle is to address symptoms like dizziness with rest breaks during instruction. One strategy for educating clients is to break down gait sequences and practice in short segments.

Question 14

A 64-year-old client with multiple sclerosis uses a manual wheelchair due to lower-extremity weakness (hip flexion 2/5 bilaterally) and poor endurance. The client can perform a pivot transfer with minimal assistance but has decreased trunk control when fatigued. Which action should the nurse take to ensure the wheelchair is correctly fitted?

  1. Position the client so there is about 1–2 finger widths between the back of the knees and the front edge of the wheelchair seat (correct answer)
  2. Teach the client to use a cane on the stronger side when walking short distances
  3. Ask the provider to prescribe a powered wheelchair before adjusting the current chair
  4. Lower the footrests so the client's knees are higher than the hips to improve stability
Explanation: This question tests knowledge of the fit and safe use of assistive devices. Proper fit and safe use of assistive devices are vital in nursing practice to prevent pressure injuries, improve comfort, and facilitate safe transfers for clients with limited mobility. Option A ensures proper fit by providing adequate seat depth, which supports the thighs and prevents sliding or shear forces. Option B is incorrect as it addresses cane use, not wheelchair fitting; C is less optimal without first optimizing the current chair; D is wrong because elevating knees above hips can increase pressure on the sacrum and reduce stability. A transferable principle is to check for 1-2 finger widths of space behind the knees to ensure correct seat depth. Another principle is to evaluate trunk control and fatigue when assessing overall wheelchair suitability. One strategy for educating clients is to explain the rationale for adjustments and encourage them to report discomfort during use.

Question 15

A 52-year-old client is postoperative after foot surgery and is using crutches with a non–weight-bearing order. Assessment: the client is able to follow directions but has decreased hand strength (3/5) due to arthritis. The nurse should prioritize which assessment finding related to crutch fit?

  1. The handgrips allow about 20–30 degrees of elbow flexion when the client holds them (correct answer)
  2. The client can carry a full laundry basket while ambulating with crutches
  3. The client's axilla rests firmly on the crutch pad for comfort during standing
  4. The client requests a provider order for a higher dose of analgesic before ambulation practice
Explanation: This question tests knowledge of the fit and safe use of assistive devices. Proper fit and safe use of assistive devices are important in nursing practice to support postoperative recovery, accommodate hand weakness, and enforce weight-bearing restrictions. Option A should be prioritized as it confirms ergonomic fit, allowing proper elbow flexion despite arthritis. Option B is less relevant as carrying loads isn't advised; C is incorrect for axilla weight-bearing; D addresses pain but not fit. A transferable principle is to ensure 20-30 degrees elbow flexion in crutch fitting. Another principle is to consider comorbidities like arthritis in assessments. One strategy for educating clients is to integrate pain management with device training sessions.

Question 16

A 57-year-old client is postoperative after right total hip arthroplasty and is using a front-wheeled walker. Assessment: weight-bearing as tolerated, hip pain 3/10, and mild weakness of the right leg (4/5). Which client statement indicates a need for further teaching about walker use?

  1. "I will push down on the walker handgrips to help support my weight."
  2. "I will move the walker forward first, then step with my surgical leg, then my other leg."
  3. "I will pull up on the walker to help me stand quickly from a chair." (correct answer)
  4. "I will keep the walker close to my body and avoid reaching too far forward."
Explanation: This question tests knowledge of the fit and safe use of assistive devices. Proper fit and safe use of assistive devices are important in nursing practice to protect surgical sites, promote healing, and prevent dislocations after procedures like hip arthroplasty. Option C indicates a need for further teaching because pulling up on the walker can cause instability and strain the surgical site, whereas pushing down is safer. Option A is correct for weight support; B describes proper gait sequence; D promotes close positioning for balance. A transferable principle is to instruct clients to push down, not pull up, on walkers for stability. Another principle is to monitor pain and weakness to ensure safe progression. One strategy for educating clients is to use video demonstrations and have them verbalize understanding before practice.

Question 17

A 61-year-old client with a progressive neurological disorder uses a manual wheelchair and reports new redness over the coccyx. Assessment shows decreased sensation in the buttocks and limited ability to perform pressure relief independently. The nurse should prioritize which assessment finding related to the wheelchair?

  1. The client can reposition or perform pressure relief at regular intervals while seated (correct answer)
  2. The client prefers the wheelchair seat to feel "soft" even if it increases pelvic sinking
  3. The client wants the wheelchair armrests raised to shoulder height for comfort
  4. The client requests a provider order for a stronger pain medication before repositioning
Explanation: This question tests knowledge of the fit and safe use of assistive devices. Proper fit and safe use of assistive devices are vital in nursing practice to prevent skin breakdown, maintain positioning, and support clients with sensory impairments. Option A should be prioritized as it confirms the client's ability to relieve pressure, essential for preventing ulcers in those with decreased sensation. Option B is less optimal as a soft seat may worsen sinking; C is incorrect for improper armrest height; D addresses pain but not wheelchair assessment. A transferable principle is to assess pressure relief capabilities in all seated clients. Another principle is to monitor skin integrity regularly for early intervention. One strategy for educating clients is to teach timed pressure relief techniques and use mirrors for self-checks.

Question 18

A 67-year-old client with a progressive neurological disorder uses a wheelchair and is preparing for discharge. Assessment: mild cognitive slowing, adequate arm strength to propel short distances, and a tendency to forget to lock the brakes. What is the most important safety instruction for this client using a wheelchair?

  1. Lock the wheelchair brakes before transfers and before reaching for items from the chair (correct answer)
  2. Keep the wheelchair in the highest seat position to make standing easier
  3. Use a two-wheeled walker inside the home instead of the wheelchair to maintain strength
  4. Ask the provider to order a sedating medication to reduce impulsive movements in the chair
Explanation: This question tests knowledge of the fit and safe use of assistive devices. Proper fit and safe use of assistive devices are vital in nursing practice to address cognitive challenges, prevent accidents, and support propulsion in neurological clients. Option A ensures safe use by emphasizing brake locking, reducing risks from forgetfulness during activities. Option B is incorrect as high seats may hinder propulsion; C is less optimal for indoor use; D is wrong as sedatives could worsen cognition. A transferable principle is to lock brakes before any wheelchair movement or reach. Another principle is to assess cognitive tendencies for safety planning. One strategy for educating clients is to use visual cues like checklists attached to the chair.

Question 19

A 74-year-old client with diabetic neuropathy and decreased proprioception is being fitted for a walker prior to discharge. The client has lower-extremity strength 4/5 but demonstrates unsteady gait and delayed reaction time; upper-extremity strength is 4/5. Which action should the nurse take to ensure the walker is correctly fitted?

  1. Ensure the walker height allows about 20–30 degrees of elbow flexion when the client grasps the hand grips (correct answer)
  2. Teach the client to keep the cane tip 6 inches lateral to the foot during the swing phase of ambulation
  3. Ask the provider to prescribe a rolling walker with hand brakes before fitting the client with the standard walker
  4. Adjust the walker so its hand grips are above the client's waist to keep the client from leaning forward during ambulation
Explanation: The correct walker fit is established by aligning the hand grips so the client's elbows flex about 20 to 30 degrees when grasping the handles; this gives relaxed arm position, effective weight bearing, and better stability when proprioception is diminished. Teaching where to place a cane tip applies to cane use, not to fitting a walker, so it cannot ensure correct walker fit. Asking the provider to prescribe a rolling walker with hand brakes changes the equipment type instead of addressing the current walker's fit, and it does not establish the needed grip height. Adjusting the hand grips above the client's waist places the walker too high, which can stress the shoulders and reduce control rather than produce a safe fit. Only checking the elbow flexion angle directly verifies that the walker is correctly fitted.

Question 20

A 44-year-old client is post-operative day 1 after open reduction and internal fixation of a left tibia fracture and is prescribed non-weight-bearing on the left leg. The client has 5/5 upper-extremity strength but becomes unsteady when attempting to stand with axillary crutches; coordination is intact. The nurse notes redness developing in both axillae after practice. Which action should the nurse take to ensure the crutches are correctly fitted?

  1. Teach the client to place weight through the axillae while stepping to improve stability and decrease pressure on the wrists.
  2. Adjust the crutches so there is a 2-finger-width space between the axilla and the top of the crutch when standing. (correct answer)
  3. Encourage the client to take larger steps with the unaffected leg to reduce fatigue during non-weight-bearing ambulation and shorten each session.
  4. Request a provider order to change the client to weight-bearing as tolerated before discharge to make crutch practice easier to perform.
Explanation: The correct response is to adjust the crutches so that, with the client standing, there is a two-finger-width space between the axilla and the top of the crutch. This fit keeps weight on the hands and arms rather than the axillae, preventing compression of the brachial plexus and blood vessels—the cause of the redness and unsteadiness. Teaching the client to place weight through the axillae would directly produce the nerve and tissue injury that correct fitting avoids. Encouraging larger steps with the unaffected leg addresses step length, not crutch fit; it can increase energy demands and fall risk rather than reduce fatigue. Requesting a provider order to change to weight-bearing as tolerated contradicts the prescribed non-weight-bearing status and is not a response to a fit problem. The issue is crutch height and placement, not the weight-bearing prescription. Therefore, the nurse should adjust the crutches to maintain the finger-width space when standing.