Nokea
The new NA is caring for the client who is at risk for a fall. Which statement by the nurse to the new NA is most important?
- A. "Remind the client to call for assistance before getting out of bed."
- B. "Clip the call light to the bedcovers so the client can find it easily."
- C. "Be sure the bed is in the lowest position when you leave the room."
- D. "Check that you have all four side rails up after you provide care."
Correct Answer: C
Rationale: Ensuring the bed is in the lowest position is critical to minimize injury from a fall, which poses a greater risk than other options. Four side rails (D) are considered a restraint and should be avoided.
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All of the following clients are in need of an emergency assessment except:
- A. a bleeding client who has an injury from falling debris.
- B. an unresponsive client.
- C. a client with an old injury.
- D. a pregnant woman with imminent delivery.
Correct Answer: C
Rationale: The client with an old injury does not need an emergency assessment because this is not a life-threatening or new situation or condition.
Which statement by the nurse is appropriate when directing an unlicensed assistive personnel (UAP) to assist a 69 year-old surgical client to ambulate for the first time?
- A. Have the client sit on the side of the bed for at least 2 minutes before helping him stand.
- B. If the client is dizzy on standing, ask him to take some deep breaths.
- C. Assist the client to the bathroom at least twice on this shift.
- D. After you assist him to the chair, let me know how he feels.
Correct Answer: A
Rationale: Give clear information to the UAP about what is expected for client safety. This instruction ensures the client is assessed for orthostatic hypotension before ambulating, reducing the risk of falls.
Which of these clients would be the highest priority for the nurse to assign to a private room?
- A. A client with a new diagnosis of tuberculosis
- B. A client with a urinary tract infection
- C. A client post-appendectomy with a surgical site infection
- D. A client with seasonal influenza
Correct Answer: A
Rationale: A client with tuberculosis requires a private room with negative pressure to prevent airborne transmission of the disease.
When teaching a 10 year-old child about their impending heart surgery, which form of explanation meets the developmental needs of this age child?
- A. Provide a verbal explanation just prior to the surgery
- B. Provide the child with a booklet to read about the surgery
- C. Introduce the child to another child who had heart surgery 3 days ago
- D. Explain the surgery using a model of the heart
Correct Answer: D
Rationale: Explain the surgery using a model of the heart. According to Piaget, the school age child is in the concrete operations stage of cognitive development. Using a model to explain the surgery meets the child’s developmental needs for concrete and visual learning.
A client being treated for hypertension returns to the community clinic for follow up. The client says, 'I know these pills are important, but I just can't take these water pills anymore. I drive a truck for a living, and I can't be stopping every 20 minutes to go to the bathroom.' Which of these is the best nursing diagnosis?
- A. Noncompliance related to medication side effects
- B. Knowledge deficit related to misunderstanding of disease state
- C. Defensive coping related to chronic illness
- D. Altered health maintenance related to occupation
Correct Answer: A
Rationale: Noncompliance related to medication side effects. The client kept his appointment, and stated he knew the pills were important. He is unable to comply with the regimen due to side effects, not because of a lack of knowledge about the disease process.