Nokea
The nurse is caring for a client who has generalized urticaria. Which disease transmission precautions should the nurse implement?
- A. Airborne precautions
- B. Droplet precautions
- C. Contact precautions
- D. Standard precautions
Correct Answer: D
Rationale: Generalized urticaria is typically non-infectious (e.g., allergic), requiring only standard precautions. Transmission-based precautions are unnecessary.
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The nurse is caring for assigned clients. Which of the following clients should the nurse identify is at the highest risk for falling?
- A. 88-year-old admitted with a chest tube secondary to pneumothorax and has a history of dementia
- B. 44-year-old admitted with heart failure, has a peripheral IV, and receiving IV furosemide
- C. 33-year-old admitted with cholecystitis, has a peripheral IV, and is receiving IV hydromorphone
- D. 28-year-old admitted with bacteremia is receiving intravenous fluids via central line and is diaphoretic
Correct Answer: A
Rationale: The 88-year-old with dementia is at highest fall risk due to age and cognitive impairment.
The nurse is caring for a client scheduled to receive enteral feedings via a nasogastric tube (NGT). The nurse plans on initially verifying placement of the NGT by
- A. Obtaining an abdominal x-ray (radiograph).
- B. Aspirating the gastric contents to assess the pH.
- C. Irrigating the tube with 15-20 mL of water to see if it flushes unobstructed.
- D. Inserting 20-30 mL of air into the NGT while auscultating the epigastrium.
Correct Answer: B
Rationale: Aspirating gastric contents to check pH (typically ≤5.5 for gastric placement) is the initial, non-invasive method to verify NGT placement. X-ray is definitive but not initial, irrigation checks patency not placement, and air auscultation is less reliable.
The nurse is performing a home safety assessment for an older adult. Which of the following client statements would require follow-up by the nurse?
- A. I will have grab bars installed in the bathroom.
- B. I placed a non-skid mat in my shower.
- C. My furniture is arranged so I can hold onto something if I need it.
- D. I secured my electrical cords against the wall behind furniture.
Correct Answer: NONE
Rationale: All statements indicate proactive safety measures (grab bars, non-skid mat, furniture for support, and secured cords) that reduce fall risk, so no follow-up is needed.
The nurse is participating in a fall and injury reduction committee to reduce falls in the inpatient environment. Which risk factors in the inpatient environment can be modified through this committee? Select all that apply.
- A. The lighting in the client rooms
- B. Staffing levels
- C. Communication failures
- D. Inadequate client assessment
- E. The prescribing of antihypertensive medications
Correct Answer: A,B,C,D
Rationale: Lighting, staffing, communication, and assessments are modifiable environmental factors. Medication prescribing is a clinical decision.
The nurse is observing a client ambulate with a walker. It would require follow-up by the nurse if the client
- A. Advances the walker 6-10 inches.
- B. Has their elbow flexed 15-30 degrees.
- C. Tilts the walker forward to help stand up from a chair.
- D. Advances the walker and then the affected leg.
Correct Answer: C
Rationale: Tilting the walker forward to stand is unsafe, risking falls. Advancing 6-10 inches, 15-30 degree elbow flexion, and proper stepping sequence are correct.