Nokea
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.
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The nurse is educating a client who has stomatitis on oral care. Which of the following recommendations would be appropriate?
- A. Recommend the client swish and spit alcohol mouthwash.
- B. Provide lemon glycerin swabs in between meals.
- C. Recommend the client swish and spit saline mouthwash.
- D. Instruct the client to cleanse their mouth with chlorhexidine.
Correct Answer: C
Rationale: Saline mouthwash soothes stomatitis without irritation. Alcohol mouthwash and lemon swabs are harsh, and chlorhexidine may be prescribed but isn’t the primary recommendation.
The nurse is teaching a client who is scheduled for a percutaneous kidney biopsy. Which of the following information should the nurse include?
- A. You will need to lay flat immediately after this procedure.
- B. A heating pad will be applied to the affected area for pain relief.
- C. Before you eat, your gag reflex will need to return.
- D. You can resume your regular activities and diet right after the procedure.
Correct Answer: A
Rationale: Lying flat post-kidney biopsy prevents bleeding complications. Heating pads are not standard, gag reflex is irrelevant, and immediate activity resumption is unsafe.
The nurse is caring for a client who has been on bed rest for 2 days following surgery. To prevent complications associated with the client's first ambulation, the nurse should plan to
- A. Encourage the client to increase fluid intake to at least 2,000 mL per day.
- B. Assist the client in performing range-of-motion (ROM) exercises.
- C. Teach the client how to use the incentive spirometer.
- D. Encourage the client to dangle their legs at the bedside.
Correct Answer: D
Rationale: Dangling legs at the bedside prevents orthostatic hypotension during first ambulation. Fluids, ROM, and spirometry are supportive but not specific to ambulation.
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.
The nurse has attended a conference on intraoperative nursing interventions for the older adult. which of the following statements by the nurse would indicate the need for additional teaching?
- A. Warming devices should be used to prevent the client from developing hypothermia
- B. The client's head and feet should be covered during surgery
- C. Clients should be slid, not lifted into the proper position
- D. Providing extra padding for clients with decreased peripheral circulation is important
Correct Answer: C
Rationale: Sliding clients instead of lifting can cause shear injuries, particularly in older adults with fragile skin. Warming devices, covering extremities, and extra padding are appropriate to prevent hypothermia and protect pressure points, indicating correct understanding.