Nokea
A nurse enters a client's room and finds her on the floor. The client's roommate reports that the client was trying to get out of bed and fell over the bedrail onto the floor. Which of the following statements should the nurse document about this incident?
- A. ''Incident report completed.''
- B. ''Client climbed over the bedrails.''
- C. ''Client found lying on the floor.''
- D. ''Client was trying to get out of bed.''
Correct Answer: C
Rationale: The correct answer is C: ''Client found lying on the floor.'' In this situation, the nurse should document factual, objective information without making assumptions. Stating that the client was found lying on the floor directly reflects what was observed. Choice A, ''Incident report completed,'' is not a statement about the incident itself and does not provide relevant information. Choice B, ''Client climbed over the bedrails,'' introduces unnecessary speculation and assumption which should be avoided when documenting incidents. Choice D, ''Client was trying to get out of bed,'' focuses on the client's behavior rather than the objective observation of the client's position when found.
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When admitting a client to an acute care facility, an identification bracelet is sent up with the admission form. In the event these do not match, the nurse's best action is to
- A. Change whichever item is incorrect to the correct information
- B. Use the bracelet and admission form until a replacement is supplied
- C. Notify the admissions office and wait to apply the bracelet
- D. Make a corrected identification bracelet for the client
Correct Answer: C
Rationale: The nurse should notify the admissions office and wait to apply the bracelet. By doing so, the nurse ensures patient safety and accuracy in identification. Changing the incorrect item (Choice A) could lead to errors and confusion in the patient's identification. Using the mismatched items until a replacement is supplied (Choice B) compromises patient safety and could result in errors during care delivery. Making a corrected identification bracelet without verifying the correct information (Choice D) could introduce further inaccuracies and risks in patient identification.
When reviewing EBP about the administration of O2 therapy, what is the recommended maximum flow rate for regulating O2 via nasal cannula?
- A. Regulate O2 via nasal cannula no more than 6L
- B. Regulate O2 via nasal cannula no more than 2L
- C. Regulate O2 via nasal cannula no more than 4L
- D. Regulate O2 via nasal cannula no more than 8L
Correct Answer: A
Rationale: The correct answer is to regulate O2 via nasal cannula no more than 6L. This flow rate is generally recommended to ensure adequate oxygen delivery without causing discomfort or potential harm to the patient. Choices B, C, and D are incorrect as they suggest flow rates that are either too low (2L, 4L) or too high (8L). A flow rate of 2L might not provide sufficient oxygen, while 4L could be inadequate for some patients. On the other hand, a flow rate of 8L could be excessive and potentially harmful, leading to complications like oxygen toxicity. Therefore, the optimal recommendation is to regulate O2 via nasal cannula at a maximum of 6L to balance effectiveness and safety.
A client in a provider's office tells the nurse that, 'I fast for several days each week to help control my weight.' The client takes several medications for various chronic issues. The nurse should explain to the client that which of the following mechanisms that result from fasting puts her at risk for medication toxicity?
- A. Increasing the metabolism of the medications over time
- B. Increasing the protein-binding response
- C. Increasing medications' transit time through the intestines
- D. Decreasing the excretion of medications
Correct Answer: B
Rationale: Fasting can lead to an increased protein-binding response of medications. This can result in a higher concentration of bound medications in the bloodstream, potentially causing toxicity as the medications may not be readily available for metabolism or excretion. Choice A is incorrect because fasting typically doesn't increase medication metabolism. Choice C is incorrect as fasting usually decreases transit time through the intestines. Choice D is incorrect since fasting generally does not decrease medication excretion.
A client with a history of falls is under the care of a nurse. Which of the following actions should the nurse take to prevent falls?
- A. Keep the client's bed in the lowest position.
- B. Encourage the client to wear non-slip socks.
- C. Place a fall risk sign on the client's door.
- D. Use a gait belt when ambulating the client.
Correct Answer: A
Rationale: Keeping the client's bed in the lowest position is an essential measure to prevent falls. Lowering the bed reduces the risk of injury if the client falls out of bed by decreasing the distance of the fall. Encouraging the client to wear non-slip socks (Choice B) may help prevent slips on smooth surfaces but does not address the risk of falls in other scenarios. Placing a fall risk sign on the client's door (Choice C) alone does not actively prevent falls but serves as a warning. Using a gait belt when ambulating the client (Choice D) is important for assisting with mobility but does not directly address fall prevention in the client's environment.
The client is being taught how to use a peak flow meter. The nurse explains that this device should be used to:
- A. Determine oxygen saturation
- B. Measure forced expiratory volume
- C. Monitor the atmosphere for the presence of allergens
- D. Provide metered doses for inhaled bronchodilator
Correct Answer: B
Rationale: A peak flow meter is used to measure forced expiratory volume, which helps in monitoring asthma. This measurement provides valuable information about how well the client's lungs are functioning and how narrow their airways are. Choice A is incorrect because determining oxygen saturation is typically done using a pulse oximeter. Choice C is incorrect as a peak flow meter is not used to monitor the atmosphere for allergens but rather to assess lung function. Choice D is incorrect as providing metered doses for inhaled bronchodilators is the function of a metered-dose inhaler, not a peak flow meter.