A nurse is reviewing a client's electronic medical record (EMR). Which of the findings should the nurse identify as a risk factor for a potential accident or injury?

History of dementia

Steady gait

History of gastric reflux

Age of 45

Answer and Explanation

The Correct Answer is A

A.   History of dementia- Dementia can impair cognitive function and increase the risk of accidents or injuries, such as falls or wandering.
B.   Steady gait- A steady gait indicates good balance and is not typically considered a risk factor for accidents or injuries.
C.   History of gastric reflux- Gastric reflux may cause discomfort but is not directly related to an increased risk of accidents or injuries.
D.   Age of 45- While age can be a risk factor for certain conditions, such as falls in older adults, being 45 years old alone does not necessarily indicate an increased risk of accidents or injuries.

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Correct Answer is A

Explanation

A) "I'm glad to have the opportunity to choose what kind of care I receive while I still can." - This statement reflects an understanding of the purpose of advance directives, which is to allow individuals to express their wishes for care while they are still able to do so.
B) "If I want life support, I'll need to sign a separate consent form first." - This statement does not accurately reflect the purpose or process of advance directives.
C) "I can't change my mind about the care I will receive once I sign my living will." - Advance directives can be updated or revoked at any time as long as the individual is of sound mind and able to make decisions.

D) "Once I fill out my living will, there will be a 1-month delay before it is legally binding." - Advance directives typically become legally effective as soon as they are completed and signed, without a waiting period.

A. Verify the bilirubin level of the tube contents. B. Auscultate for air insufflation. C. Request a chest x-ray. D. Check the pH level of gastric contents.

Correct Answer is C

Explanation

A. Verifying the bilirubin level of the tube contents is not a reliable method for confirming tube placement and may not provide accurate information.
B. Auscultating for air insufflation can help detect tube placement in the respiratory tract but may not reliably confirm placement in the gastrointestinal tract.
C. Requesting a chest x-ray is the most reliable method for confirming the placement of a feeding tube, as it allows visualization of the tube's position relative to anatomical landmarks.
D. Checking the pH level of gastric contents can help differentiate between gastric and respiratory placement but may not provide definitive confirmation of tube placement.

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A nurse is reviewing a client's electronic medical record (EMR). Which of the findings should the nurse identify as a risk factor for a potential accident or injury?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is reinforcing teaching about advance directives with a client who has terminal colorectal cancer. Which of the following statements by the client indicates an understanding of the teaching?

Correct Answer is A

Explanation

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Correct Answer is C

Explanation

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