Nokea
The nurse is caring for several clients in a long-term care facility. Which interventions should the nurse implement to reduce the risk of injury from falls? Select all that apply.
- A. Avoid administering ibuprofen at night
- B. Secure the call button to the side of the bed
- C. Keep the bed in the lowest position
- D. Place fall risk bands on clients at risk of falling
- E. Reposition clients off of bony prominences every two hours
Correct Answer: B,C,D
Rationale: Securing the call button, keeping the bed low, and using fall risk bands reduce fall risk. Ibuprofen and repositioning are unrelated to fall prevention.
You may also like to solve these questions
The nurse is assisting a client in selecting appropriate food options for dumping syndrome. Which foods would be suitable choices? Select all that apply.
- A. Rice cereal
- B. Pastries
- C. Chicken breast
- D. Cola
- E. Scrambled eggs
Correct Answer: A,C,E
Rationale: Rice cereal, chicken breast, and scrambled eggs are low-sugar, high-protein options suitable for dumping syndrome. Pastries and cola are high-sugar, triggering symptoms.
The nurse assesses a client's central venous catheter dressing, and it appears loose and wet. The nurse should take which action?
- A. Reinforce the dressing with paper tape
- B. Remove the dressing and the central vascular device
- C. Apply a clean occlusive dressing to the site
- D. Clean the site and apply a new sterile dressing
Correct Answer: D
Rationale: Cleaning the site and applying a new sterile dressing prevents infection and ensures catheter security.
The nurse plans care for a client immediately post-operative. The nurse should initially assess the client's
- A. respiratory status
- B. tolerance to by-mouth (PO) fluids
- C. pain level
- D. ability to move the extremities
Correct Answer: A
Rationale: Respiratory status is the priority assessment post-operatively to ensure airway patency and adequate oxygenation, following the ABCs (airway, breathing, circulation) of care. Pain, fluid tolerance, and extremity movement are important but secondary to ensuring respiratory stability.
The nurse cares for a client in the outpatient surgical center who is scheduled for a cholecystectomy
Item 1 of 1
Nurses' Note
0730 – The client arrives at the preoperative area with his family. He reports that he is anxious about the procedure. The pre-operative assessment was completed at this time. 20-gauge peripheral vascular access established in the right antecubital space. + blood return and flushes without resistance. The client reports no pain at the insertion site.
The nurse reviews the completed pre-operative assessment.Select the findings on the assessment that require follow-up
- A. ID verified and band applied
- B. The surgeon has not obtained informed consent
- C. Client took his prescribed phenytoin with a sip of water this morning
- D. The client reports his last meal and fluid intake was the previous day at 2200
- E. The client stated he was going to drive himself home after the procedure
Correct Answer: B,D
Rationale: Assessment items requiring follow-up include the informed consent not yet obtained by the surgeon. Before further preoperative activities may continue, the nurse must ensure this is completed to avoid unnecessary diagnostic testing and intervention. Additionally, the client will not be permitted to drive themselves home after this procedure because this involves general anesthesia. Activities requiring significant concentration, operation of heavy machinery, or driving are typically prohibited 24 hours following the initiation of general anesthesia.
The other assessment findings do not require intervention. ID banding and verification are expected during the preoperative process. The client's ID will also be verified in the intraoperative and postoperative processes. Medications such as phenytoin can be taken with a sip of water to prevent seizure activity. The client has been NPO for approximately eight hours, sufficient time to prevent aspiration.
The nurse is caring for a child immediately postoperative following a left ear myringotomy. The nurse should position the child
- A. left lateral recumbent
- B. prone
- C. right lateral recumbent
- D. modified trendelenburg
Correct Answer: C
Rationale: Positioning the child on the right lateral recumbent side (operative ear up) post-myringotomy facilitates drainage from the left ear and prevents pressure on the surgical site. Left lateral recumbent or prone positions could obstruct drainage, and modified Trendelenburg is not indicated.