Nokea
Which of the following statements from a client may indicate that they are at a higher risk for a fall?
- A. I would like to get out of bed but would like to put on my non-skid socks first.
- B. Can you make sure the two bedrails are raised before leaving the room?
- C. I think I'm ready to walk a longer distance with the cane today.
- D. I need to get out of bed to go to the bathroom now. I cannot find my glasses but cannot wait.
Correct Answer: D
Rationale: A client who is visually impaired without their assistive devices could be at a higher risk for a fall when ambulating.
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A safety measure to implement when transferring a client with hemiparesis from a bed to a wheelchair is:
- A. standing the client and walking him or her to the wheelchair.
- B. moving the wheelchair close to client's bed and standing and pivoting the client on his unaffected extremity to the wheelchair.
- C. moving the wheelchair close to client's bed and standing and pivoting the client on his affected extremity to the wheelchair.
- D. having the client stand and push his body to the wheelchair.
Correct Answer: B
Rationale: Moving the wheelchair close to client's bed and having him stand and pivot on his unaffected extremity to the wheelchair is safer because it provides support with the unaffected limb.
The client voided 300 mL after having an indwelling urinary catheter removed six hours ago. A bladder scan immediately after the void showed that the client has a postvoid residual (PVR) volume of 250 mL. What should the nurse conclude from this finding?
- A. This is an expected finding following catheter removal.
- B. The client's bladder function is approximately 50% of normal.
- C. The bladder scan was not done within 20 minutes of voiding.
- D. The PVR volume is evidence of incomplete bladder emptying.
Correct Answer: D
Rationale: D: A PVR of 250 mL indicates incomplete bladder emptying, as normal PVR is less than 50 mL. A: High PVR is not expected. B: PVR doesn't quantify bladder function percentage. C: No evidence suggests timing was incorrect.
A nurse assesses a 83 year-old female's venous ulcer for the second time that is located near the right medial malleolus. The wound is exhibiting purulent drainage and the patient has limited mobility in her home. Which of the options is the best course of action?
- A. Encourage warm water soaks to the right foot.
- B. Notify the case manager of the purulent drainage.
- C. Determine the patient's pulse in the right ankle.
- D. Recommend increased activity to reduce the purulent drainage.
Correct Answer: A
Rationale: A determination of arterial blood flow should be made, prior to encouraging increased activity, or notifying additional team members.
The dietitian prescribes a 24-hour calorie count for the malnourished hospitalized client. Which action should be taken by the nurse?
- A. Ask the client to recall at the end of the day the food and beverages consumed.
- B. Inform the client how to count the calories in the food and beverages consumed.
- C. Inform the client that a record will be maintained of food and beverages consumed.
- D. Ask the client to identify the food groups and foods that are being consumed in each.
Correct Answer: C
Rationale: C: Recording food intake ensures accurate calorie counts. A: Recall is unreliable. B: Clients don't calculate calories in hospital. D: Food groups don't provide calorie data.
Hazards of improper splinting include:
- A. aggravation of a bone or joint injury
- B. reduced distal circulation
- C. delay in transport of a client with a life-threatening injury
- D. all of the above
Correct Answer: D
Rationale: Improper splinting can worsen injuries, impair circulation, and delay critical transport, posing significant risks to the client.