A home health nurse is providing teaching to an older adult client who is at risk for falls.
Which of the following statements by the client indicates a need for further teaching?
"I will have my vision checked."
"I will put socks on when I get out of bed."
"I will put a safety bar near my toilet."
"I will put a night-light in the hallway."
The Correct Answer is B
A. Having vision checked is a positive step to prevent falls by addressing potential visual impairments.
B. Wearing socks when getting out of bed increases the risk of slipping, indicating a need for further teaching.
C. Placing a safety bar near the toilet is a preventive measure against falls.
D. Putting a night-light in the hallway helps improve visibility and reduce the risk of tripping
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Vest restraints are not appropriate for seizure precautions. Restraints are generally not recommended as the primary intervention for seizure management.
B. The use of tongue blades during a seizure is not recommended and could pose a risk of injury.
C. Oxygen setup is crucial for managing a client during and after a seizure to ensure proper oxygenation.
D. Neck brace is not necessary for seizure precautions and may pose a risk during a seizure episode.
Correct Answer is ["150"]
Explanation
The question is about calculating the IV infusion rate for a given solution and volume.
The formula for the infusion rate is: (volume in mL / time in hours) x drop factor in gtts/mL = infusion rate in gtts/min
The drop factor is usually given on the IV tubing package and varies depending on the type of tubing used.
For this question, we can assume a drop factor of 15 gtts/mL, which is common for macrodrip tubing.
Plugging in the numbers, we get: (1200 mL / 8 hr) x 15 gtts/mL = 2250 gtts/hr
To convert from gtts/hr to mL/hr, we divide by the drop factor: 2250 gtts/hr / 15 gtts/mL = 150 mL/hr
Therefore, the nurse should set the IV pump to deliver 150 mL/hr.
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