Nokea
The nurse cares for geriatric clients. What would the nurse emphasize as an increased risk for this client population?
- A. Blepharitis and chalazion
- B. Myopia and strabismus
- C. Exophthalmos and presbyopia
- D. Glaucoma and cataracts
Correct Answer: D
Rationale: Glaucoma and cataracts are common age-related eye conditions, increasing vision loss risk. Other conditions are less prevalent or age-specific.
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The nurse is part of a committee tasked with reducing medical errors in the nursing unit. Which of the following recommendations should the nurse make to the committee? Select all that apply.
- A. Increase the number of verbal orders given from primary healthcare providers
- B. Nurse-to-nurse bedside handoff reporting
- C. Handoff reporting using the ISBAR framework
- D. Ensure staff are taking uninterrupted breaks
- E. Increase the lighting around the medication dispensing machines
Correct Answer: B,C,D,E
Rationale: Bedside handoffs, ISBAR framework, breaks, and better lighting reduce errors. Verbal orders increase error risk.
The home health nurse is caring for a 67-year-old female client with progressive multiple sclerosis.
Item 4 of 6
Current Medications
Nurses' Notes
• cephalexin 500 mg p.o. every six hours for 10 days
• diazepam 5 mg p.o. daily PRN muscle spasm
• multivitamin 1 tablet daily
• ergocalciferol 10,000 international units p.o. Daily
For each potential intervention, click to specify whether the intervention is indicated or not indicated for the client with progressive multiple sclerosis.
- A. Obtain a referral for occupational therapy for fatigue and energy conservation training
- B. Promote rest by encouraging daytime napping over consistent nighttime sleep
- C. Encourage the client to walk to the mailbox at midday for sun exposure
- D. Instruct the client to increase fluid intake with caffeinated beverages
- E. Obtain an order for physical therapy for home mobility and coordination evaluation
- F. Educate the client on the early signs of cystitis and the importance of completing antibiotics
- G. Educate the client to wear slippers while walking inside
Correct Answer: A,E,F,G
Rationale: Occupational therapy, physical therapy, cystitis education, and slipper use are indicated to address fatigue, mobility, infection prevention, and fall risk. Daytime napping and midday sun exposure are not indicated due to heat sensitivity and inconsistent sleep.
A client with a history of falls is admitted to the medical-surgical unit. The nurse should plan to implement which intervention to reduce this client's risk of falling?
- A. Encouraging the client to ambulate independently to improve muscle strength.
- B. Verify that the bed alarm is enabled during client rounding.
- C. Implementing a fall risk assessment every two days
- D. Implementing a restrictive mobility policy to minimize the potential of falls.
Correct Answer: B
Rationale: Verifying the bed alarm ensures immediate notification of movement, reducing fall risk for a client with a fall history.
The nurse has attended a continuing education conference about infection control precautions. It would indicate a correct understanding of the education if the nurse is observed?
- A. using dedicated client-care equipment for a client with Clostridium difficile.
- B. wearing a particulate respirator mask (N95) while caring for a client with epiglottitis, due to Haemophilus influenzae type b.
- C. placing a surgical mask on a client being transported with radiology who has infectious mononucleosis.
- D. keeping the door closed for a client with cryptococcal meningitis.
Correct Answer: A
Rationale: Dedicated equipment for C. difficile prevents transmission. N95 is not needed for epiglottitis, masks are not required for mononucleosis transport, and cryptococcal meningitis does not require a closed door.
The nurse is caring for a client with a Sengstaken-Blakemore tube. The nurse performs safety checks at the beginning of the shift and ensures which priority item is readily available at the bedside?
- A. Trach kit
- B. Scissors
- C. Obturator
- D. Yankauer suctioning
Correct Answer: B
Rationale: A Sengstaken-Blakemore tube is used for esophageal variceal bleeding and has balloons that can cause airway obstruction if inflated improperly. Scissors must be at the bedside to cut the tube in an emergency. Trach kits, obturators, and Yankauer suction are not relevant.