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A nurse is caring for an older adult client in a long-term care facility. Which of the following measures should the nurse take first when assisting with planning the client's care?

Determining the client's mobility

Explaining the roles of the RN, licensed practical nurse, and assistive personnel

Introducing health care team members to the client

Understanding the client's routine for his own care at home

Answer and Explanation

The Correct Answer is D

A. Determining the client's mobility

Important for safety and fall prevention, but not the first priority during care planning.

B. Explaining the roles of the RN, licensed practical nurse, and assistive personnel

This is part of orientation and education but does not help in personalized care planning.

C. Introducing health care team members to the client

While courteous and important for building rapport, it’s not the first step in individualized care planning.

D. Understanding the client's routine for his own care at home

This helps in personalizing the care plan to maintain the client’s independence and preferences, especially for older adults in long-term care.

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Correct Answer is B

Explanation

A. Use metal clips to secure the wrap:

While metal clips are commonly provided with elastic bandages, they can easily become dislodged and may cause injury. Tape or self-adhesive wraps are often safer and more secure.

B. Adjust the pressure or tension as needed:

This allows for proper circulation and comfort. Bandages should be snug but not tight, and pressure may need to be adjusted for swelling or anatomical differences.

C. Overlap turns of the bandage equally:

This is a correct technique but not the most critical factor for effectiveness and safety. Equal overlapping helps provide uniform pressure, but adjusting tension as needed is more essential.

D. Face the patient and wrap from proximal to distal:

Wrapping should always go from distal to proximal to promote venous return and reduce edema. Wrapping proximal to distal is incorrect and can impair circulation.

A. Perhaps B. True C. False D. Maybe

Correct Answer is B

Explanation

B. True

Skeletal traction involves the surgical placement of hardware (e.g., pins, wires) directly into bone to apply a constant pulling force for fracture alignment or immobilization

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A nurse is caring for an older adult client in a long-term care facility. Which of the following measures should the nurse take first when assisting with planning the client's care?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is applying an elasticized bandage to the leg of a patient. To perform this procedure correctly, the nurse should:

Correct Answer is B

Explanation

Please indicate whether the following statement is true or false. Skeletal traction may require surgical placement of pins, tongs, screws, or wires anchored to a bone.

Correct Answer is B

Explanation

The nurse placing a patient following knee replacement surgery into a continuous passive motion (CPM) machine has the responsibility to:

A nurse is assisting with the ambulation of a client with the use of a gait belt, who becomes light-headed and begins to fall. Which of the following actions should the nurse take?

The nurse, in order to prevent the cast from chafing, will instruct the patient for home care to _______ the rough edges with adhesive tape.

A nurse is collecting data from a client who has required strict bed rest for 1 week. Which of the following findings should the nurse identify as an indication that the client is ready to ambulate?

A nurse in an urgent care center is caring for a client who fell and injured her ankle. The ankle appears swollen and ecchymotic. While the client waits for the x-ray technician, which of the following actions should the nurse take? (Select all that apply.)

A certified nursing assistant (CNA) is assisting a patient into a wheelchair. The nurse intervenes if the CNA has:

The nurse explains that range of motion exercises are necessary so that movement improves venous circulation by:

The nurse is aware that the maximum weight that can be applied with a skin traction is