Nokea
The occupational health nurse is conducting an in-service on reducing back injuries in the workplace. It would be correct for the nurse to identify that the most common location of back injuries is in the
- A. Cervical spine.
- B. Lumbar spine.
- C. Thoracic spine.
- D. Pelvis.
Correct Answer: B
Rationale: The lumbar spine is the most common site for back injuries due to its weight-bearing role and flexibility. Other areas are less frequently injured.
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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.
The nurse is inserting an indwelling urinary catheter in a male client. It would be appropriate for the nurse to inflate the catheter's balloon when
- A. Meeting resistance.
- B. As soon as urine is observed in the tubing.
- C. After advancing to the point of bifurcation.
- D. After fully advancing the length of the catheter.
Correct Answer: C
Rationale: The balloon should be inflated after advancing the catheter to the bifurcation (Y-connector), ensuring it is in the bladder. Inflating too early or fully advancing risks trauma or improper placement.
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 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 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.