Nokea
What are the key factors in assessing a patient's fall risk?
- A. Assess the patient's age and mobility
- B. Evaluate the patient's medication list for sedatives
- C. Assess the patient's vision and hearing
- D. Check for recent falls and cognitive impairment
Correct Answer: A
Rationale: The correct answer is A. Assessing the patient's age and mobility are key factors in determining fall risk. Age can affect balance and reaction time, while mobility influences the patient's stability. Choices B, C, and D are important considerations in assessing a patient's fall risk as well, but age and mobility play a more direct role in determining the patient's susceptibility to falls.
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A client with a sprained right ankle is learning to walk with a cane. What action demonstrates effective teaching?
- A. The client advances the cane 18 inches in front of the foot
- B. The client holds the cane in the left hand
- C. The client advances the cane and the right leg simultaneously
- D. The client holds the cane with the elbow flexed at 60°
Correct Answer: B
Rationale: When a client has a sprained right ankle, they should hold the cane in the opposite hand (left hand) to the affected leg for better support and balance. This positioning helps to reduce the weight on the injured leg while providing stability. Option A is incorrect because advancing the cane too far in front can lead to loss of balance. Option C is incorrect as it does not provide the necessary support for the injured leg. Option D is incorrect as the elbow should be slightly flexed but not necessarily at a specific angle.
A nurse is reinforcing teaching about food selection with a client who has a moderate burn injury. Which of the following foods should the nurse recommend as being high in vitamin C?
- A. Tomatoes
- B. Carrots
- C. Avocados
- D. Apricots
Correct Answer: A
Rationale: Tomatoes are high in vitamin C, which is crucial for wound healing, making them an excellent recommendation for a client with a burn injury. Carrots, avocados, and apricots are not as rich in vitamin C compared to tomatoes, and therefore, they are not the best choice for promoting healing in this scenario.
A client who is postoperative following a cholecystectomy has a urine output of 25 mL/hr. Which of the following findings should the nurse report to the provider?
- A. Abdominal pain radiating to the right shoulder.
- B. Absent bowel sounds.
- C. Brown drainage on the surgical dressing.
- D. Urine output of 25 mL/hr.
Correct Answer: D
Rationale: A urine output below 30 mL/hr indicates a potential complication, such as hypovolemia or renal impairment, and should be reported. Abdominal pain radiating to the right shoulder can be common after a cholecystectomy due to referred pain from the diaphragm, whereas absent bowel sounds may be expected temporarily postoperatively. Brown drainage on the surgical dressing is typical in the early postoperative period and may represent old blood or other normal discharge.
A nurse is caring for a client with an NG tube who reports nausea and a decrease in gastric secretions. What is the nurse's next step?
- A. Administer an antiemetic
- B. Irrigate the NG tube with sterile water
- C. Increase the suction setting
- D. Replace the NG tube
Correct Answer: B
Rationale: The correct next step for the nurse is to irrigate the NG tube with sterile water. This action helps relieve blockages that may be causing the symptoms of nausea and decreased gastric secretions. Administering an antiemetic (Choice A) may mask the underlying issue without addressing the possible blockage. Increasing the suction setting (Choice C) is not indicated without first addressing the potential blockage. Replacing the NG tube (Choice D) is also premature before attempting to clear any obstructions.
A nurse is contributing to the plan of care for an older adult client who has difficulty sleeping. Which of the following interventions should the nurse include?
- A. Give a bedtime snack
- B. Encourage a short nap in the afternoon
- C. Encourage exercise right before bed
- D. Establish a regular exercise routine 2 hours or more before bedtime
Correct Answer: D
Rationale: The correct answer is D. Establishing a regular exercise routine at least 2 hours before bedtime promotes better sleep in older adults. Giving a bedtime snack (choice A) may disrupt sleep due to digestion, encouraging a short nap in the afternoon (choice B) can interfere with nighttime sleep, and encouraging exercise right before bed (choice C) can increase alertness and make it harder to fall asleep.