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Nurse is caring for newly admitted client with history of falls. What is the priority action by the nurse?
- A. Complete fall-risk assessment
- B. Educate client & family on fall risks
- C. Complete physical assessment
- D. Survey client's belongings
Correct Answer: A
Rationale: The correct answer is A: Complete fall-risk assessment. This is the priority action because it allows the nurse to identify specific risk factors contributing to the client's falls. By completing a fall-risk assessment, the nurse can implement appropriate interventions to prevent future falls. Choice B is incorrect because education should come after assessing the risk factors. Choice C is not the priority as the client's risk for falls needs to be addressed first. Choice D is irrelevant to addressing the immediate safety concern of falls.
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Nurse collecting hx & physical exam data from middle adult. Nurse should expect to find decreases in which physiologic functions? (Select all that apply.)
- A. Metabolism
- B. Ability to hear low-pitched sounds
- C. Gastric secretion
- D. Far vision
- E. Glomerular filtration
Correct Answer: A,C,E
Rationale: The correct answers are A, C, and E. As individuals age, metabolism decreases due to changes in muscle mass and activity levels. Gastric secretion decreases, leading to decreased absorption of certain nutrients. Glomerular filtration rate decreases with age, affecting kidney function. Choice B is incorrect as hearing high-pitched sounds is more commonly affected with age. Choice D is incorrect as near vision is usually affected, not far vision.
An RN is making assignments for client care to an LPN at the beginning of shift. Which of the following assignments should the LPN question?
- A. Assisting a client who is 24h post-op to use incentive spirometer
- B. Collecting clean-catch urine specimen
- C. Providing nasopharyngeal suctioning for pneumonia client
- D. Replacing cartridge & tubing on PCA pump
Correct Answer: D
Rationale: The LPN should question replacing cartridge & tubing on PCA pump (Choice D) because this task involves manipulating the patient's medication delivery system, which is beyond the LPN's scope of practice. LPNs are not trained to handle complex medication administration devices like PCA pumps, as this requires a higher level of knowledge and skill typically reserved for RNs. The LPN should advocate for clarification from the RN or delegate this task to someone with the appropriate training. Choices A, B, and C are within the LPN's scope of practice and do not require specialized training like manipulating a PCA pump.
Nurse educator is discussing facility protocol for tornados with staff. Which should nurse include in instructions? (Select all that apply.)
- A. Open doors to client rooms
- B. Place blankets over clients who are confined to beds
- C. Move beds away from windows
- D. Draw shades & close drapes
- E. Relocate ambulatory clients in hallways back to rooms
Correct Answer: B,C,D
Rationale: The correct answers are B, C, and D. Placing blankets over clients in beds provides protection from debris. Moving beds away from windows minimizes the risk of glass injuries. Drawing shades and closing drapes can prevent glass shards from entering the room. Opening doors to client rooms (A) is incorrect as it can create a draft and increase the risk of injury. Relocating ambulatory clients back to rooms (E) is unnecessary if they are safe in hallways. Choices F and G are not provided in the question. In summary, the correct instructions focus on protecting clients from debris and glass injuries during a tornado.
Nurse preparing wellness presentation for families at community center. When discussing health screenings for adolescents, which info about scoliosis should nurse include? (Select all that apply.)
- A. Scoliosis is more common in girls than in boys
- B. Loss of height is often first sign of scoliosis
- C. Scoliosis screening is essential during adolescent growth spurt
- D. Slouching is common cause of scoliosis, especially in adolescents
- E. Scoliosis is forward curvature of spine
Correct Answer: A,C
Rationale: Correct Answer: A, C
A: Scoliosis is more common in girls than in boys - This is correct. Scoliosis is indeed more prevalent in girls compared to boys, with a ratio of about 7:1.
C: Scoliosis screening is essential during adolescent growth spurt - This is correct. Screening during the adolescent growth spurt is crucial as this is when scoliosis progression is most likely to occur.
B: Loss of height is often first sign of scoliosis - This is incorrect. The first sign of scoliosis is typically asymmetry or a visible curvature of the spine.
D: Slouching is a common cause of scoliosis, especially in adolescents - This is incorrect. Slouching is not a direct cause of scoliosis; it can exacerbate existing curvature but does not cause scoliosis.
E: Scoliosis is a forward curvature of the spine - This is incorrect. Scoliosis involves a lateral (side
The nurse is caring for a group of medical-surgical patients. The unit has been notified of a fire on an adjacent wing of the hospital. The nurse quickly formulates a plan to keep the patients safe. Which actions will the nurse take? Select all that apply
- A. Close all doors.
- B. Note evacuation routes.
- C. Note oxygen shut-offs.
- D. Move bedridden patients in their bed.
- E. Wait until the fire department arrives to act.
- F. Use type B fire extinguishers for electrical fires.
Correct Answer: A, B, C, D
Rationale: Correct Answer: A, B, C, D
Rationale:
A: Close all doors - By closing doors, the nurse can prevent the spread of smoke and fire, protecting patients.
B: Note evacuation routes - Knowing evacuation routes ensures a safe and efficient evacuation if needed.
C: Note oxygen shut-offs - Turning off oxygen can reduce the risk of fire spreading and explosions.
D: Move bedridden patients in their bed - Moving bedridden patients quickly and safely is crucial for their well-being during an emergency.
Summary:
E: Waiting for the fire department is not proactive and can waste valuable time in ensuring patient safety.
F: Using type B fire extinguishers for electrical fires is incorrect as type C extinguishers are recommended for electrical fires.
G: There is no information provided for this option.