Nokea
Which findings documented in the history of an older client should require the nurse to implement an accident prevention protocol? Select all that apply.
- A. Range of motion is limited.
- B. Peripheral vision is decreased.
- C. Transmission of hot impulses is delayed.
- D. The client reports incidences of nocturia.
- E. High-frequency hearing tones are perceptible.
- F. Voluntary and autonomic reflexes are slowed.
Correct Answer: A,B,C,D,F
Rationale: The physiological changes that occur during the aging process increase the client's risk for accidents. Musculoskeletal changes include a decrease in muscle strength and function, lessened joint mobility, and limited range of motion. Sensory changes include a decrease in peripheral vision and lens accommodation, delayed transmission of hot and cold impulses, and impaired hearing as high-frequency tones become less perceptible. Nervous system changes include slowed voluntary and autonomic reflexes. Genitourinary changes may include nocturia.
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The nurse is planning to instruct a client with a diagnosis of chronic vertigo about safety measures to prevent exacerbation of symptoms or injury. Which instruction is most important for the nurse to incorporate in a teaching plan?
- A. Turn the head slowly when spoken to.
- B. Remove throw rugs and clutter in the home.
- C. Drive at times when the client does not feel dizzy.
- D. Walk to the bedroom and lie down when vertigo is experienced.
Correct Answer: B
Rationale: The client should maintain the home in a clutter-free state and have thrown rugs removed because the effort of trying to regain balance after slipping could trigger the onset of vertigo. To further prevent vertigo attacks, the client should change position slowly and should turn the entire body, not just the head, when spoken to. The client with chronic vertigo should avoid driving and using public transportation. The sudden movements involved in each could precipitate an attack. If vertigo does occur, the client should immediately sit down or lie down (rather than walking to the bedroom) or grasp the nearest piece of furniture.
A new nurse is learning the functions of the unit's nurse manager. Which functions are included? Select all that apply.
- A. Recruiting new employees
- B. Conducting regular staff meetings
- C. Assisting staff in meeting annual goals
- D. Monitoring professional standards of practice on the nursing unit
- E. Delegating problem-solving of client or family complaints to all nursing staff
- F. Writing prescriptions for primary health care providers (HCPs) when conducting rounds
Correct Answer: A,B,C,D
Rationale: Responsibilities of the nurse manager (middle manager) include recruiting new employees (interviewing and hiring), conducting regular staff meetings, assisting staff in meeting annual goals for the unit and systems needed to accomplish goals, monitoring professional standards of practice on the nursing unit, developing an ongoing staff development plan, conducting routine staff evaluations, acting as a role model, submitting staff schedules for the unit, conducting regular client rounds and problem-solving client and family complaints, establishing and implementing a unit quality improvement plan, and conducting rounds with primary HCPs. The nurse is not responsible for writing prescriptions for HCPs when conducting rounds; the HCP is responsible for writing prescriptions.
The nurse is preparing the bedside for a postoperative parathyroidectomy client. The nurse should ensure that which specific priority item is at the client's bedside?
- A. Cardiac monitor
- B. Tracheotomy set
- C. Intermittent gastric suction
- D. Underwater seal chest drainage system
Correct Answer: B
Rationale: Respiratory distress caused by hemorrhage and swelling and compression of the trachea is a primary concern for the nurse managing the care of a postoperative parathyroidectomy client. An emergency tracheotomy set is always routinely placed at the bedside of the client with this type of surgery, in anticipation of this potential complication. Although a cardiac monitor may be attached to the client in the postoperative period, it is not specific to this type of surgery. Options 3 and 4 also are not specifically needed with the surgical procedure.
The nurse is assigned to care for a client who is in traction. Which intervention by the nurse should ensure a safe environment for the client?
- A. Making sure that the knots are at the pulleys sites
- B. Checking the weights to be sure that they are off the floor
- C. Making sure that the head of the bed is kept at a 90-degree angle
- D. Monitoring the weights to be sure that they are resting on a firm surface
Correct Answer: B
Rationale: To achieve proper traction, weights need to be free-hanging, with knots kept away from the pulleys. The head of the bed is usually kept low to provide countertraction. Weights are not to be kept resting on a firm surface.
The nurse places a hospitalized client with a diagnosis of active tuberculosis in a private, well-ventilated isolation room. In addition, which action should the nurse take before entering the client's room?
- A. Wash the hands.
- B. Wash the hands and wear a gown and gloves.
- C. Wash the hands and place a high-efficiency particulate air (HEPA) respirator over the nose and mouth.
- D. The nurse needs no special precautions, but the client is instructed to cover his or her mouth and nose when coughing or sneezing.
Correct Answer: C
Rationale: Tuberculosis is a highly communicable disease caused by Mycobacterium tuberculosis. The nurse wears a HEPA respirator when caring for a client with active tuberculosis. Hands are always thoroughly washed before and after caring for the client. Option 1 is an incomplete action. Option 2 is also inaccurate and incomplete. Gowning is only indicated when there is a possibility of contaminating clothing. Option 4 is an incorrect statement because special precautions are needed.