A nurse is caring for a client who had a cerebrovascular accident and is at risk for falls. The nurse should recognize that which of the following is an appropriate safety precaution?

Monitor the client at least once every hr.

Assign the client to a private room.

Request a PRN prescription for restraints.

Keep four side rails up while the client is in bed.

Answer and Explanation

The Correct Answer is A

A.   Monitoring the client at least once every hour is an appropriate safety precaution to assess the client's condition and prevent falls.
B.   Assigning the client to a private room may not directly address the risk of falls and may not be necessary for fall prevention.
C.   Requesting a PRN prescription for restraints should not be the first line of defense for fall prevention and should only be considered when other interventions are ineffective or inappropriate.
D.   Keeping four side rails up while the client is in bed can be a restraint and may increase the risk of injury. It is not a recommended approach for fall prevention.

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Correct Answer is D,A,B,C

Explanation

Correct order: D A B C

D. Ask about the type of tobacco product used.

A. Teach the client cessation strategies.

B. Develop a cessation plan with the client.

C. Assist the client in modifying the plan if necessary.

A. Have the guard sign a release of information form. B. Tell the guard to submit an inmate inquiry form to the warden. C. Complete an incident report. D. Instruct the guard to ask the inmate.

Correct Answer is C

Explanation

A. Having the guard sign a release of information form may not be appropriate in an emergency situation, and immediate action is needed to address the injury.
B. Telling the guard to submit an inmate inquiry form to the warden may delay necessary medical intervention in an emergency.
C. Completing an incident report is appropriate to document the situation and the care provided It is not necessary to disclose the inmate's HIV status in the report.

D. Instructing the guard to ask the inmate is not a proper approach to handling a medical emergency. The nurse should focus on providing immediate care to the injured inmate.

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A nurse is caring for a client who had a cerebrovascular accident and is at risk for falls. The nurse should recognize that which of the following is an appropriate safety precaution?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

42. A nurse is providing teaching to a client who uses tobacco products. (Move the steps that the nurse should take into the box on the right, placing them in the correct order of performance. All steps must be used.)

Correct Answer is D,A,B,C

Explanation

A guard at a prison brings an injured inmate to the facility clinic. The inmate is bleeding, and the guard asks the nurse about the inmate's HIV infection status. Which of the following actions by the nurse is appropriate?

Correct Answer is C

Explanation

To plan culturally competent care, a nurse should consider that:

A nurse is caring for a client who has a stage II pressure ulcer. Which of the following products should the nurse use to treat the ulcer?

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