Nokea
A nurse is assessing an older adult client's risk for falls. Which of the following assessments should the nurse use to identify the client's safety needs? (Select all that apply)
- A. Lacrimal apparatus
- B. Pupil clarity
- C. Appearance of bulbar conjunctivae
- D. Visual fields
- E. Visual acuity
Correct Answer: D,E
Rationale: The correct assessments for identifying an older adult client's safety needs are visual fields (D) and visual acuity (E). Visual fields evaluate peripheral vision, important for detecting obstacles and hazards. Impaired visual acuity can affect depth perception and balance, increasing fall risk. Lacrimal apparatus (A) assesses tear production, not directly related to fall risk. Pupil clarity (B) and appearance of bulbar conjunctivae (C) are more related to eye health but do not directly assess fall risk in older adults.
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A nurse is caring for a client who has dementia. Which of the following interventions should the nurse take to minimize the risk for injury to the client?
- A. Use a bed exit alarm system.
- B. Raise four side rails while the client is in bed.
- C. Apply one soft wrist restraint.
- D. Dim the lights in the client's room.
Correct Answer: A
Rationale: The correct answer is A: Use a bed exit alarm system. This intervention is crucial in minimizing the risk of injury for a client with dementia as it alerts the nurse when the client attempts to get out of bed, preventing falls. This approach promotes client safety by allowing timely intervention. Raising four side rails (B) may restrict the client's movement and cause agitation or attempts to climb over the rails, increasing the risk of injury. Applying a soft wrist restraint (C) is considered a restrictive measure and should be avoided unless absolutely necessary due to the risk of causing emotional distress and physical harm to the client. Dimming the lights (D) in the client's room may increase confusion and disorientation, leading to a higher risk of falls.
A nurse is planning to insert a peripheral IV catheter for an older adult client. Which of the following actions should the nurse plan to take?
- A. Insert the catheter at a 45-degree angle.
- B. Place the client's arm in a dependent position.
- C. Shave excess hair from the insertion site.
- D. Initiate IV therapy in the veins of the hand.
Correct Answer: A
Rationale: The correct answer is A: Insert the catheter at a 45-degree angle. When inserting a peripheral IV catheter for an older adult client, the nurse should aim to insert the catheter at a 45-degree angle to reduce the risk of complications such as infiltration. Inserting at this angle helps to ensure proper placement in the vein and reduces the likelihood of the catheter slipping out or causing discomfort to the client. Placing the client's arm in a dependent position (B) is not necessary and could potentially cause unnecessary discomfort. Shaving excess hair from the insertion site (C) is not recommended as it can irritate the skin and increase the risk of infection. Initiating IV therapy in the veins of the hand (D) may not be the best choice for an older adult client due to potential fragility of hand veins and difficulty with vein accessibility.
A nurse is performing a home safety assessment for a client who is receiving supplemental oxygen. Which of the following observations should the nurse identify as proper safety protocol?
- A. The client uses a wool blanket on their bed.
- B. The client identifies the location of the fire extinguisher.
- C. The client stores an oxygen tank in a secure outdoor shed.
- D. The client has a weekly inspection checklist for oxygen equipment.
Correct Answer: D
Rationale: The correct answer is D because a weekly inspection checklist for oxygen equipment ensures that the equipment is functioning properly and reduces the risk of potential hazards. Option A is incorrect because wool blankets can create static electricity, which is a fire hazard. Option B is not directly related to oxygen safety. Option C is incorrect as storing an oxygen tank in an outdoor shed may expose it to extreme temperatures or moisture.
A nurse is providing discharge teaching to a client about self-administering heparin. Which of the following instructions should the nurse include in the teaching?
- A. Stir the needle to 15° before administration.
- B. Aspire the syringe prior to administration.
- C. Administer the medication to the abdomen.
- D. Massage the site following the injection.
Correct Answer: C
Rationale: Correct Answer: C - Administer the medication to the abdomen.
Rationale: Heparin is typically administered subcutaneously. The abdomen has a larger subcutaneous tissue area compared to other sites, allowing for better absorption and reducing the risk of tissue damage. Administering heparin in the abdomen also minimizes the risk of hitting blood vessels and nerves. It is important to rotate injection sites to prevent tissue damage and ensure consistent absorption.
Summary of other choices:
A: Stirring the needle to a specific angle is unnecessary and can increase the risk of needle breakage or improper administration.
B: Aspiration is not required for subcutaneous injections as it may cause unnecessary tissue trauma.
D: Massaging the site after injection can lead to bruising and discomfort.
E, F, G: Choices left blank as they are not relevant to the administration of heparin.
A nurse is educating a client who has a terminal illness about declining resuscitation in a living will. The client asks, 'What would happen if I arrived at the emergency department and I had difficulty breathing?' Which of the following responses should the nurse make?
- A. We would consult the person appointed by your health care proxy to make decisions.
- B. We would give you oxygen through a tube in your nose.
- C. You would be unable to change your previous wishes about your care.
- D. We would insert a breathing tube while we evaluate your condition.
Correct Answer: A
Rationale: The correct answer is A: We would consult the person appointed by your health care proxy to make decisions. This response aligns with the client's living will and respects their wishes for declining resuscitation. By involving the designated health care proxy, the healthcare team ensures that decisions are made in accordance with the client's preferences.
Choice B is incorrect because providing oxygen through a tube does not address the client's concerns about declining resuscitation. Choice C is incorrect as it does not address the client's current situation or need for support in the emergency department. Choice D is incorrect as it goes against the client's expressed wishes in the living will. It is important to prioritize the client's autonomy and respect their decisions regarding end-of-life care.