Nokea
The nurse is gathering evidence for a quality improvement committee focused on fall prevention. To provide the highest quality scholarly evidence, the nurse plans on gathering findings from
- A. expert opinions.
- B. randomized controlled trials (RCTs).
- C. C. quantitative studies.
- D. D. qualitative studies.
Correct Answer: B
Rationale: Randomized controlled trials (B) provide the highest level of evidence for fall prevention due to their rigorous methodology. Expert opinions (A), quantitative studies (C), and qualitative studies (D) are lower in the evidence hierarchy.
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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.
The nurse is performing an assessment on an older adult. Which finding requires immediate followup?
- A. dysphagia
- B. stress incontinence
- C. dry, flaky skin
- D. hearing loss
Correct Answer: A
Rationale: Dysphagia (A) in older adults risks aspiration and malnutrition, requiring immediate follow-up to ensure safety. Stress incontinence (B), dry skin (C), and hearing loss (D) are common but less urgent concerns.
The nurse is caring for a client who has been brought to the emergency department after a severe car accident. They require immediate life-saving surgery; however, they are unconscious and unable to consent to the operation. Which of the following is the best course of action?
- A. Ask a friend who was with the client to sign the consent form.
- B. Attempt calling a family member to obtain consent.
- C. Call the on-staff nursing supervisor and request a court order for the surgery.
- D. Immediately transport the client to the operating department without obtaining consent.
Correct Answer: D
Rationale: Implied consent applies for unconscious clients needing life-saving surgery (D), allowing immediate transport to the operating room. Friends (A) cannot legally consent, family contact (B) delays care, and court orders (C) are unnecessary in emergencies.
The nurse is caring for the following assigned clients. The nurse should initially follow-up with the client who
- A. is repeatedly washing their hands.
- B. talking over others during group therapy.
- C. yelling and shouting at others.
- D. is voluntarily admitted and requesting discharge.
Correct Answer: C
Rationale: Yelling and shouting at others (C) indicates potential agitation or safety risk, requiring immediate follow-up to de-escalate and ensure unit safety. Hand washing (A), interrupting therapy (B), and discharge requests (D) are less urgent.
The nurse is caring for a group of children on the medical-surgical unit. The nurse should initially follow up on the child who
- A. is receiving treatment for Hirschsprung's disease and has a temperature of 101°F (38.3°C).
- B. has an indwelling urinary catheter and reports burning at the insertion site.
- C. has scant blood in their newly established ostomy pouch.
- D. has friends writing words on their fiberglass cast with different colored markers.
Correct Answer: A
Rationale: A fever of 101°F in Hirschsprung’s disease (A) suggests possible enterocolitis, a life-threatening complication requiring immediate follow-up. Catheter burning (B), scant ostomy blood (C), and cast writing (D) are less urgent, as they are expected or non-threatening.