Nokea
The medical-surgical nurse is preparing for the admission of an older adult following a ground-level fall. The nurse should prioritize teaching the client
- A. how to use the telephone and order meals.
- B. their prescribed medications for the shift.
- C. the prescribed pain management plan.
- D. how to operate the call light.
Correct Answer: D
Rationale: Teaching how to operate the call light (D) is the priority to ensure the client can request assistance, preventing falls and ensuring safety. Telephone use (A), medications (B), and pain management (C) are important but secondary to immediate safety needs.
You may also like to solve these questions
According to the National Council of State Boards of Nursing, which of the following are included in the five rights of delegation? Select all that apply.
- A. Right task
- B. Right circumstance
- C. Right person
- D. Right direction and communication
Correct Answer: A, B, C, D
Rationale: The five rights of delegation per NCSBN include right task (A), circumstance (B), person (C), direction/communication (D), and supervision (not listed). All listed options are correct.
The nurse knows that the concept of management is most closely associated with:
- A. Decision-making, problem-solving, and priority setting.
- B. Inspirational abilities and coaching.
- C. Visionary abilities and supervision.
- D. Motivational and visionary abilities.
Correct Answer: A
Rationale: Management is closely associated with decision-making, problem-solving, and priority setting (A), which are core functions of organizing and coordinating care. Inspirational (B), visionary (C), and motivational (D) abilities align more with leadership than management.
The nurse enters a client's room and finds the client lying on the floor and appearing unresponsive. The nurse should initially
- A. initiate a code blue.
- B. assess the client's respiratory effort.
- C. assess the carotid pulse.
- D. shout the client's name.
Correct Answer: B
Rationale: Assessing respiratory effort (B) is the initial step for an unresponsive client to determine if breathing is present, guiding further action. Shouting (D), checking pulse (C), or initiating a code (A) follow assessment.
The nurse is planning a staff development conference about the care of transgender clients. Which of the following information should the nurse include? Select all that apply.
- A. At the start of the interview, inquire about the client's preferred pronoun.'
- B. Utilize binary gender terms on healthcare documentation.'
- C. Transgender individuals feel a variance between gender and natal sex.'
- D. Clients who are transgender may be reluctant to seek healthcare.'
- E. Inquire about any current or future plans for hormone therapy.'
Correct Answer: A, C, D, E
Rationale: Inquiring about pronouns (A), recognizing gender variance (C), acknowledging healthcare reluctance (D), and discussing hormone therapy (E) are inclusive and relevant. Binary gender terms (B) are inappropriate, as they exclude non-binary identities.
The nurse is caring for a client requesting to leave against medical advice. The nurse barricades the client in their room because they feel that the client is not safe to go home. The nurse is demonstrating
- A. false imprisonment.
- B. malpractice.
- C. negligence.
- D. invasion of privacy.
Correct Answer: A
Rationale: Barricading a client (A) constitutes false imprisonment, as it unlawfully restricts their freedom. Malpractice (B) involves substandard care, negligence (C) requires harm from a breach of duty, and invasion of privacy (D) involves unauthorized disclosure.