A nurse is collecting data from a client who has an acute condition. Which of the following findings should the nurse identify as increasing the risk for potential client injuries?

Hearing acuity intact

Oriented to person only

Full range of motion bilateral lower extremities

Ability to use call light

Answer and Explanation

The Correct Answer is B

A)   Hearing acuity intact - Intact hearing acuity does not directly increase the risk for potential client injuries.
B)   Oriented to person only - Being oriented to person only may indicate confusion or disorientation, which can increase the risk for potential client injuries due to impaired decision-making or awareness of surroundings.
C)   Full range of motion bilateral lower extremities - Having a full range of motion in the lower extremities does not directly increase the risk for potential client injuries.
D)   Ability to use call light - The ability to use a call light indicates the client's ability to seek assistance, which reduces the risk for potential client injuries.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is A

Explanation

A) Placing the restraint across the client's chest - This is not a safe practice since it can restrict breathing increasing the risk of asphyxiation.
B) Applying the restraint over the client's gown - Restraints should be applied over the clients gown and not directly to the client's skin to prevent friction and skin breakdown.
C) Using a quick-release tie to secure the restraint - Quick-release ties are important for ensuring that restraints can be quickly removed in case of an emergency.
D) Tying the restraint to the bed frame – Tying restraints on the bed frame is the recommended practice. Restraints should not be tied on the bed rails to avoid injuries if the side rails are released.

A. Observe the client's skin integrity every 2 hr. B. Use a square knot to secure the client's restraint to the bed. C. Ensure that 2 fingers can be placed between the restraint and the client. D. Tie the ends of the restraint to the client's bed rail. E. Pad bony prominences before applying a restraint.

Correct Answer is ["A","C","E"]

Explanation

A) Observe the client's skin integrity every 2 hr. - Regular skin assessments are essential to monitor for any signs of skin breakdown or injury related to the use of restraints.
B) Use a square knot to secure the client's restraint to the bed. - A quick-release knot, not a square knot, should be used to secure restraints for easy removal in case of an emergency.

C) Ensure that 2 fingers can be placed between the restraint and the client. - This ensures that the restraint is not too tight, allowing for circulation and preventing injury.
D) Tie the ends of the restraint to the client's bed rail. - Restraints should not be tied to the bed rail as it can increase the risk of injury and entrapment.
E) Pad bony prominences before applying a restraint. - Padding bony prominences helps prevent pressure injuries and discomfort for the client.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

A nurse is collecting data from a client who has an acute condition. Which of the following findings should the nurse identify as increasing the risk for potential client injuries?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is observing an assistive personnel (AP) apply a belt restraint to a client. Which of the following actions by the AP requires intervention by the nurse?

Correct Answer is A

Explanation

A nurse at a long-term care facility is reinforcing teaching with a newly licensed nurse about the proper use of restraints. Which of the following instructions should the nurse include in the teaching? (Select all that apply.)

Correct Answer is ["A","C","E"]

Explanation

A nurse is delegating client care to an assistive personnel (AP). Which of the following tasks should the nurse assign to the AP?

A nurse is setting up a sterile field in a client's room. Which of the following actions should the nurse take?

A charge nurse is observing a newly licensed nurse caring for a client group. Which of the following statements by the newly licensed nurse indicates an understanding of infection control principles?

A nurse is collecting data from a client who has a stage 4 pressure injury. Which of the following supplies should the nurse obtain?

A nurse is assisting in the transfer of a client who has left-sided weakness from a bed to a chair. Which of the following actions should the nurse take?

A nurse is collecting a urine specimen for culture and sensitivity from a client who has an indwelling urinary catheter. Which of the following actions should the nurse take?

A nurse is caring for a client who refuses their morning dose of antihypertensive medication. The client tells the nurse, "I'm not going to take this medication because it makes me sick and dizzy." Which of the following actions should the nurse take first?

A nurse is caring for a client who follows a lacto-vegetarian diet. Which of the following food choices should the nurse recommend?