A nurse is assisting with the care of a client.

Exhibits

A nurse in a provider's office is assisting with the review of fall risk data collected on a client. Which of the following findings places the client at risk for a fall? Select all that apply.

Uses a cane to ambulate

Throw rugs in kitchen

Electrical cord on floor over walkway

Grab bar in bathroom

Macular degeneration

Answer and Explanation

Correct Answer : B,C,E

A.   While a cane can be helpful for balance, it doesn't necessarily increase fall risk. In fact, it can help reduce the risk.
B.   Throw rugs can be tripping hazards, especially for individuals with visual impairments like macular degeneration.
C.   Electrical cords can cause tripping and falls, especially in areas with high foot traffic.
D.   A grab bar can actually help prevent falls, especially in the bathroom where there is a risk of slipping.
E.   This eye condition can impair vision, making it difficult to see obstacles and potential hazards, increasing the risk of falls.

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Correct Answer is B

Explanation

A. This is not one of the five rights of delegation. While ensuring that tasks are assigned in the appropriate environment is important, it is not a formal component of delegation principles.
B. This concept is critical in delegation but is not specifically one of the "Five Rights." Effective communication is necessary to ensure that the AP understands the task, its importance, and any specific instructions or expectations.
C. This is not one of the five rights of delegation. However, it does relate to when tasks should be delegated and ensuring that they are completed within a timeframe that is appropriate for patient care. The timing aspect is generally integrated into the context of the task rather than identified as a standalone right.
D. This is also not one of the five rights of delegation. While documentation is essential for maintaining accurate patient records and communication, it does not directly fall under the formal rights of delegation.

A. Macular degeneration, B. Cataracts C. Diabetic retinopathy D. Glaucoma

Correct Answer is B

Explanation

A. This condition affects the central portion of the retina, causing blurred vision in the center of the visual field.
B. A cataract is a clouding of the lens in the eye that affects vision. This clouding can cause blurred vision, sensitivity to light, and difficulty seeing at night.
C. This is a complication of diabetes that damages the blood vessels in the retina. It can cause blurred vision, floaters, and even blindness.
D. This is a condition that damages the optic nerve. It often causes a gradual loss of peripheral vision.

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A nurse is assisting with the care of a client. Exhibits A nurse in a provider's office is assisting with the review of fall risk data collected on a client. Which of the following findings places the client at risk for a fall? Select all that apply.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is preparing to delegate tasks to an assistive personnel (AP). The nurse should identify which of the following as one of the five rights of delegation?

Correct Answer is B

Explanation

A nurse is caring for a client who has a cloudy, opaque area over the lens of one eye. The nurse should identify that this is a manifestation of which of the following visual impairments?

Correct Answer is B

Explanation

A nurse is collecting data on a client for manifestations of pain. Which of the following findings is an objective indicator of pain?

A nurse is assisting with teaching a newly licensed nurse about pain. Which of the following is an example of acute pain?

When showering a patient, which of the following actions should the nurse take to ensure patient safety?

A nurse is assisting with the plan of care for a client who is immobile and is experiencing urinary retention. The nurse should plan to monitor the client for which of the following?

What is the correct way to use a cane while walking?

A charge nurse is teaching a newly licensed nurse about the use of critical pathways. Which of the following should the charge nurse include?

A nurse is discussing time management strategies with another nurse. The nurse should include which of the following as an example of a time management strategy?

A nurse is documenting in a client's health record using the subjective, objective, assessment, and plan (SOAP) charting model. Which of the following information should be included in the subjective component?

A nurse is assisting with the care of a client.

Exhibits

A nurse in a provider's office is assisting with the review of fall risk data collected on a client. Which of the following findings places the client at risk for a fall? Select all that apply.