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.

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

Explanation

A. Ensure the oxygen delivery system is at least 8 feet from any heat source- This is important to prevent any risk of fire or combustion around the oxygen source.
B. Adjust the oxygen flow rate as needed to ease breathing- oxygen flow rate should not be adjusted without consulting a healthcare provider, as it can lead to complications.
C. Take antibiotic medication with or without food- The client should be advised to take the antibiotic medication as directed by the healthcare provider, which may be with or without food depending on the specific medication.

D. Decrease the steroid dose each day- It's not advisable to decrease the steroid dose each day without medical guidance.
E. Take antibiotics for 10 days- Completing the full course of antibiotics is crucial to ensure effective treatment of pneumonia and prevent recurrence or antibiotic resistance.
F. Store the oxygen cylinder wrench with the oxygen tank- storing the oxygen cylinder wrench with the oxygen tank ensures it is readily available in case of an emergency.
G. Take steroid medication in the morning- Taking steroid medication in the morning helps mimic the body's natural cortisol secretion pattern and reduces the risk of insomnia or sleep disturbances.

A. The stoma protrudes slightly from the abdomen. B. The stoma bleeds lightly when touched. C. The stoma appears dark in color. D. The stoma is draining a small amount of liquid stool.

Correct Answer is C

Explanation

A) The stoma protrudes slightly from the abdomen. - A slightly protruding stoma is a normal finding following colostomy surgery and does not require reporting.
B) The stoma bleeds lightly when touched. - Minor bleeding may occur, especially in the immediate postoperative period, and typically resolves without intervention.
C) The stoma appears dark in color. - A dark or dusky stoma may indicate compromised blood supply and should be reported promptly to the provider.
D) The stoma is draining a small amount of liquid stool. - Stoma output varies among individuals and can include liquid stool, which is a normal finding post-colostomy surgery.

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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

Exhibits The nurse is reinforcing discharge teaching with the client and their caregiver. Which of the following information should the nurse include? Select all that apply.

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

Explanation

A nurse is collecting data from a client who is 2 days postoperative following the placement of a colostomy. Which of the following findings should the nurse report to the provider?

Correct Answer is C

Explanation

A nurse is reinforcing discharge teaching about fecal occult blood testing with a client. Which of the following instructions should the nurse include in the teaching?

A nurse in a long-term care facility is preparing to administer medications to a client who has advanced dementia and does not have an identification and. Which of the following actions should the nurse take to verify the client's identity?

A nurse is contributing to planning an interprofessional conference for a client who reports concerns about their BMI of 30. Which of the following members of the interprofessional team should the nurse include?

A nurse is reinforcing teaching with an older adult client who has urinary incontinence. Which of the following instructions should the nurse include?

A nurse is preparing to insert an indwelling urinary catheter and is verifying the client's express consent for this procedure. Which of the following actions should the nurse take?

A nurse is reinforcing teaching about end-of-life care with the partner of a client. Which of the following statements should the nurse make?

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?

A nurse is recording the intake and output (I&O) for a client. The client consumed 8 oz of milk, 10 oz of water, 4 oz of gelatin, 1 egg, 1 piece of bacon, and 2 biscuits. Which of the following volumes should the nurse record on the I&O?