Nokea
A client with a history of falls is admitted to the medical-surgical unit. The nurse should plan to implement which intervention to reduce this client's risk of falling?
- A. Encouraging the client to ambulate independently to improve muscle strength.
- B. Verify that the bed alarm is enabled during client rounding.
- C. Implementing a fall risk assessment every two days
- D. Implementing a restrictive mobility policy to minimize the potential of falls.
Correct Answer: B
Rationale: Verifying the bed alarm ensures immediate notification of movement, reducing fall risk for a client with a fall history.
You may also like to solve these questions
The nurse is caring for a client who is two days postoperative following a right femoral popliteal bypass surgery. The client reports worsening pain, and the assessment showed swelling and ecchymosis at the incision sites. The nurse should initially
- A. Apply pressure to sites with sandbag
- B. Palpate pedal pulses
- C. Assess for signs of claudication
- D. Apply warm compress to incision sites
Correct Answer: B
Rationale: Worsening pain, swelling, and ecchymosis at the incision sites suggest possible complications such as hematoma or compromised vascular flow. Palpating pedal pulses is the priority to assess the patency of the bypass graft and ensure adequate distal perfusion. Applying pressure or warm compresses could exacerbate bleeding or swelling, and claudication assessment is less urgent than confirming vascular integrity.
The home health nurse is caring for a 67-year-old female client with progressive multiple sclerosis.
Item 4 of 6
Current Medications
Nurses' Notes
• cephalexin 500 mg p.o. every six hours for 10 days
• diazepam 5 mg p.o. daily PRN muscle spasm
• multivitamin 1 tablet daily
• ergocalciferol 10,000 international units p.o. Daily
For each potential intervention, click to specify whether the intervention is indicated or not indicated for the client with progressive multiple sclerosis.
- A. Obtain a referral for occupational therapy for fatigue and energy conservation training
- B. Promote rest by encouraging daytime napping over consistent nighttime sleep
- C. Encourage the client to walk to the mailbox at midday for sun exposure
- D. Instruct the client to increase fluid intake with caffeinated beverages
- E. Obtain an order for physical therapy for home mobility and coordination evaluation
- F. Educate the client on the early signs of cystitis and the importance of completing antibiotics
- G. Educate the client to wear slippers while walking inside
Correct Answer: A,E,F,G
Rationale: Occupational therapy, physical therapy, cystitis education, and slipper use are indicated to address fatigue, mobility, infection prevention, and fall risk. Daytime napping and midday sun exposure are not indicated due to heat sensitivity and inconsistent sleep.
The nurse is discussing infection control practices in the nursing unit. Which client requires droplet precautions? A client with Select all that apply.
- A. Diagnosed with rubella.
- B. A new diagnosis of pharyngeal diphtheria.
- C. Receiving chemotherapy via an implanted port.
- D. Pulmonary tuberculosis receiving nebulizer treatments.
- E. A skin abscess that tested positive for Klebsiella.
Correct Answer: A,B
Rationale: Rubella and pharyngeal diphtheria require droplet precautions due to respiratory transmission. TB requires airborne, chemotherapy does not require isolation, and Klebsiella abscess requires contact precautions.
The nurse is caring for a client ordered a 24-hour urine specimen collection. What action should the nurse take after collecting the first specimen?
- A. Place it in a separate container and later add to the collection
- B. Discard the sample and then start the collection immediately thereafter
- C. Discard the sample and then start the collection for twelve hours
- D. Save it as part of the total urine collection
Correct Answer: B
Rationale: The first voided specimen is discarded to start the 24-hour collection fresh, ensuring accurate timing. Saving or partially collecting is incorrect.
The nurse cares for a client and receives a phone call from the laboratory department regarding a critical sodium level of 122 mEq/L (mmol/L) [135-145 mEq/L, mmol/L]. The nurse should take which initial action?
- A. Notify the primary healthcare provider (PHCP)
- B. Implement seizure precautions
- C. Read back the result for verification
- D. Recollect the laboratory specimen
Correct Answer: C
Rationale: Reading back the critical result verifies accuracy, the first step before further action. Notifying the provider, seizure precautions, or recollecting follow verification.