Nokea
Nurse is caring for newly admitted client with history of falls. Which is priority action by 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 helps identify specific risks the client faces, allowing for tailored interventions to prevent falls. Educating the client and family (B) is important but assessing risk comes first. Completing a physical assessment (C) is also important but not the priority in this case. Surveying belongings (D) is not as urgent as assessing the client's fall risk.
You may also like to solve these questions
Nurse on med-surg unit is informed that mass casualty event occurred & it's necessary to discharge clients to make beds available for injury victims. Which clients can be safely discharged? (Select all that apply.)
- A. Client who's dehydrated & receiving IV fluid/electrolytes
- B. Client with NG tube to treat small bowel obstruction
- C. Client who's scheduled for TURP (prostate resection)
- D. Client who is 24h post-op after mastectomy
- E. Client scheduled for appendectomy
Correct Answer: C,D
Rationale: Correct Answer: C, D
Rationale:
1. Client scheduled for TURP (prostate resection): This client can be safely discharged as the procedure is elective and not urgent.
2. Client who is 24h post-op after mastectomy: This client is stable post-operation and can be discharged with appropriate follow-up care.
Summary of other choices:
A: Client who's dehydrated & receiving IV fluid/electrolytes - This client needs continued treatment and monitoring.
B: Client with NG tube to treat small bowel obstruction - This client requires ongoing treatment and observation.
E: Client scheduled for appendectomy - This client needs urgent surgical intervention and cannot be safely discharged.
Nursing instructor reviewing documentation with students. Which of the following legal guidelines should they follow when documenting in client record? (Select all that apply.)
- A. Cover errors with correction fluid, & write in correct info
- B. Put date & time on all entries
- C. Document objective data, leaving out opinions
- D. Use as many abbreviations as possible
- E. Wait until the end of shift to document
Correct Answer: B, C
Rationale: Correct Answer: B, C
Rationale:
B: Putting date & time on all entries is crucial for legal purposes to establish timeline of events.
C: Documenting objective data without opinions ensures accuracy and prevents subjective bias.
Summary:
A: Covering errors with correction fluid is not recommended as it can be seen as tampering with records.
D: Using excessive abbreviations can lead to misinterpretation and errors in documentation.
E: Waiting until the end of the shift to document can result in missing crucial information or delayed updates.
Client who will undergo neurosurgery in 1 week tells the nurse in office that he will prepare his advance directives before he goes to the hospital. Which of the following statements by the client indicates to the nurse that he understands them?
- A. I'd rather have my brother make decisions for me, but I know it has to be my wife.
- B. I know they won't go ahead with the surgery unless I prepare these forms.
- C. I plan to write that I don't want them to keep me on a breathing machine.
- D. I will get my regular doctor to approve my plan before I hand it in at the hospital.
Correct Answer: C
Rationale: The correct answer is C: "I plan to write that I don't want them to keep me on a breathing machine." This statement indicates understanding of advance directives as it demonstrates the client's specific wishes regarding life-sustaining treatment. By stating his preference clearly, the client shows he understands the purpose of advance directives in communicating his healthcare decisions.
Choice A: This indicates a lack of understanding as the client is unsure about who should make decisions for him, showing confusion about the purpose of advance directives.
Choice B: While this choice shows awareness of the importance of advance directives, it does not demonstrate understanding of the content or purpose of the document.
Choice D: Involving the regular doctor is not necessary for advance directives and does not indicate comprehension of the document's purpose.
In summary, choice C is correct as it directly addresses a specific healthcare decision, while the other choices do not demonstrate a clear understanding of advance directives.
A mother tells nurse that her 2 yo has temper tantrums. Child says 'no' every time mother tries to help her get dressed. Nurse explains that developmentally the toddler is...
- A. Trying to gain her independence
- B. Developing sense of trust
- C. Manifesting anger management problem
- D. Attempting to finish a project she started
Correct Answer: A
Rationale: The correct answer is A: Trying to gain her independence. At age 2, children often exhibit behaviors to assert their independence. By saying 'no' and resisting help with dressing, the toddler is showing a desire to do things on her own and asserting her autonomy. This behavior aligns with the typical developmental stage of toddlers seeking independence and autonomy. Choices B, C, and D are incorrect because they do not align with the typical behaviors and developmental milestones of a 2-year-old. Choice B (Developing sense of trust) is more characteristic of infancy, choice C (Manifesting anger management problem) is not appropriate for a toddler's behavior in this context, and choice D (Attempting to finish a project she started) does not reflect the developmental stage of a 2-year-old.
When entering a client's room to change a dressing, the nurse notes the client is coughing & sneezing. When preparing a sterile field, it's important the nurse...
- A. Keep sterile field at least 6 ft away from client's bedside
- B. Instruct client to not cough/sneeze during dressing change
- C. Place mask on client to limit the spread of microorganisms into the surgical wound
- D. Keep box of Kleenex nearby for client to use during dressing change
Correct Answer: C
Rationale: The correct answer is C because placing a mask on the client helps limit the spread of microorganisms into the surgical wound. This is crucial to prevent infection. Choice A is incorrect because the distance does not necessarily prevent microorganism spread. Choice B is unrealistic as it's difficult for a client to control coughing/sneezing. Choice D does not address the prevention of microorganism spread.