Nokea
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.
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The nurse is caring for a client who has soft-limb wrist restraints applied. The highest priority for the nurse is to
- A. Provide the client with opportunities to discuss their feelings.
- B. Document the neurovascular assessments.
- C. Assess the client's mood and affect.
- D. Offer nutrition and hydration.
Correct Answer: B
Rationale: Neurovascular assessments ensure circulation and safety, the highest priority with restraints. Other actions are important but secondary.
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.
Which of the following children would the nurse identify as a priority for having the greatest risk for choking and suffocating?
- A. A toddler playing with his 9-year-old brother's construction set.
- B. A 5-year-old eating yogurt for a snack.
- C. An infant asleep in her crib without a blanket.
- D. A 3-year-old drinking a glass of juice.
Correct Answer: A
Rationale: A toddler playing with small construction set pieces is at high risk for choking due to the size and accessibility of the objects.
The nurse is planning to perform a dressing change for a client with a stage three pressure injury. The nurse should initially perform which action?
- A. Gather all the necessary equipment
- B. Use non-sterile gloves to remove the old dressing
- C. Document the characteristics of the wound
- D. Administer prescribed oral pain medication
Correct Answer: A
Rationale: Gathering equipment ensures efficiency and sterility. Non-sterile gloves, documentation, and pain medication follow preparation.
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.