Nokea
Charge nurse is designating room assignments for clients. Based on her knowledge of fall prevention, which client should be assigned to room closest to the nursing station?
- A. 43-year-old client post-op following laparoscopic cholecystectomy
- B. 61-year-old client being admitted for telemetry to rule out MI
- C. 50-year-old client post-op following open reduction internal fixation of ankle
- D. 79-year-old client post-op following below-the-knee amputation
Correct Answer: D
Rationale: The correct answer is D. The 79-year-old client post-op following below-the-knee amputation should be assigned to the room closest to the nursing station for fall prevention. This is because this client may have mobility challenges and an increased risk of falls due to the recent surgery and potential use of assistive devices. Placing the client closer to the nursing station allows for closer monitoring and quicker assistance in case of any fall-related incidents.
Choice A is incorrect because a 43-year-old client post-op following laparoscopic cholecystectomy is not necessarily at an increased risk for falls related to mobility issues.
Choice B is incorrect as a 61-year-old client being admitted for telemetry to rule out MI is not specifically at a higher risk for falls compared to the client post-amputation.
Choice C is incorrect as a 50-year-old client post-op following open reduction internal fixation of the ankle may have mobility limitations, but the risk of falls is typically lower compared to a client post
You may also like to solve these questions
A nurse is caring for a client 24h post-op following abdominal surgery and suspects inadequate pain management. Which findings support this suspicion?
- A. Client seems easily agitated
- B. Client is nonadherent with coughing and deep breathing
- C. Client accepts pain medication every 6-7h instead of 4-6h
- D. Client reports tenderness in right lower leg
- E. Client's vital signs: HR 110/min
Correct Answer: B,C,E
Rationale: The correct answer is B, C, and E. Choice B indicates nonadherence with coughing and deep breathing, which is essential for preventing postoperative complications such as pneumonia. Choice C suggests the client is not taking pain medication as frequently as prescribed, indicating inadequate pain relief. Choice E shows an elevated heart rate, which can be a sign of uncontrolled pain. Choices A and D do not directly relate to inadequate pain management post-op. A client being agitated (choice A) can have various causes, and tenderness in the right lower leg (choice D) is not specific to poor pain management.
The nurse is assessing a patient who reports a previous fall and is using the SPLATT acronym. Which questions will the nurse ask the patient? Select all that apply.
- A. Where did you fall?
- B. What time did the fall occur?
- C. What were you doing when you fell?
- D. What types of injuries occurred after the fall?
- E. Did you obtain an electronic safety alert device after the fall?
- F. What are your medical problems that may have caused the fall?
Correct Answer: A, B, C, D
Rationale: The correct answers are A, B, C, and D. The SPLATT acronym stands for Symptoms, Previous falls, Location, Activity during the fall, Time of the fall, and Trauma sustained. Therefore, the nurse should ask where the patient fell (A), what time the fall occurred (B), what the patient was doing when they fell (C), and what types of injuries occurred after the fall (D) to gather comprehensive information about the fall event. These questions help assess the circumstances surrounding the fall, potential risk factors, and any resulting injuries. Choices E and F are incorrect as they do not directly align with the components of the SPLATT acronym and may not provide relevant information for assessing the fall event.
Nurse providing discharge instructions to client with a prescription for oxygen use at home. What should the nurse teach about using oxygen safely? (Select all that apply)
- A. Family members who smoke must be at least 10 ft from client when oxygen is on
- B. Nail polish shouldn't be used near client receiving oxygen
- C. A 'No Smoking' sign should be placed on front door
- D. Cotton bedding/clothing should be replaced with items made from wool
- E. Fire extinguisher should be readily available in home
Correct Answer: B,C,E
Rationale: Correct Answer: B, C, E
Rationale:
B: Nail polish shouldn't be used near client receiving oxygen to prevent flammability risk as it contains volatile chemicals that can ignite.
C: A 'No Smoking' sign should be placed on the front door to remind visitors and family members to not smoke near oxygen, reducing fire risk.
E: Fire extinguisher should be readily available in the home to quickly address any potential fires related to oxygen use, ensuring safety.
Summary:
A: Keeping family members who smoke at least 10 ft away is important, but not the most critical safety measure.
D: Replacing cotton with wool clothing does not directly impact oxygen safety.
F & G: No information provided.
Nurse is talking with 45 yo client with no specific family hx of cancer or DM, about planning routine screenings. Which client statement indicates client understands how to proceed?
- A. So I don't need colon cancer procedure for another 2-3 yrs
- B. For now, I should continue to have mammogram each year
- C. B/c doctor just did pap smear, I'll come back next year for another
- D. I had my blood glucose test last year so I won't need it again till next year
Correct Answer: B
Rationale: The correct answer is B. The client's statement indicates an understanding of the recommended screening guideline for mammograms for a 45-year-old individual with no specific family history of cancer. Yearly mammograms are typically recommended starting at age 40 for early detection of breast cancer. Choice A is incorrect as colon cancer screening is recommended starting at age 45-50, not in 2-3 years. Choice C is incorrect as Pap smears are typically recommended every 3-5 years, not yearly. Choice D is incorrect as blood glucose testing is usually recommended annually for individuals at risk for diabetes.
Nurse caring for 19-year-old client who is sexually active & has come to college health clinic for first time for checkup. Which intervention should nurse perform to determine client's health promotion & disease prevention?
- A. Measure the vital signs
- B. Encourage HIV screening
- C. Determine client's risk factors
- D. Instruct client to use condoms
Correct Answer: C
Rationale: The correct answer is C: Determine client's risk factors. This is the most appropriate intervention to assess the client's health promotion and disease prevention needs. By identifying the client's risk factors such as sexual behaviors, substance use, family history, and lifestyle choices, the nurse can tailor health education and intervention strategies to promote overall well-being.
A: Measure the vital signs - While important, vital signs do not directly assess health promotion and disease prevention needs in a sexually active young adult.
B: Encourage HIV screening - Important for sexual health but does not address a comprehensive assessment of health promotion and disease prevention.
D: Instruct client to use condoms - Important recommendation for safe sex practices but does not address the broader health promotion and disease prevention needs of the client.