A nurse is working a night shift and caring for several clients at risk for falls. Which of the following actions should the nurse take? (Select all that apply.)

Instruct the clients to use the call light.

Move overbed tables away from the bed.

Place a fall risk wristband on each of the clients.

Perform client checks every 4 hr.

Keep the clients' rooms dark.

Answer and Explanation

Correct Answer : A,B,C,D

A. Instruct the clients to use the call light.

Encouraging clients to use the call light enables them to request assistance when needed, reducing the risk of falls if they need help to move or get out of bed.

B. Move overbed tables away from the bed.

Clearing the area around the bed, including overbed tables, reduces obstacles and potential hazards that clients might trip over or get tangled in.

C. Place a fall risk wristband on each of the clients.

Identifying clients at risk for falls by using wristbands helps alert all healthcare staff to take necessary precautions and provide appropriate assistance to prevent falls.

D. Perform client checks every 4 hr.

Regular client checks allow the nurse to monitor their condition, reposition them if necessary, assist with toileting needs, and ensure they're safe, especially during the night when falls might be more likely.

E. Keep the clients' rooms dark.

Keeping the room dimly lit during the night can help clients sleep better but should still provide enough light for safe movement. Complete darkness might increase the risk of falls if clients need to move around.

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Correct Answer is ["0.5"]

Explanation

To administer lorazepam 1 mg PO to an older adult client who has insomnia and who cannot swallow oral tablets, the nurse should use the lorazepam oral solution 2 mg/mL.

The nurse should calculate the dose by using the formula: Dose (mL) = Desired dose (mg) / Available dose (mg/mL).

In this case, the desired dose is 1 mg and the available dose is 2 mg/mL.

Therefore, the dose (mL) = 1 mg / 2 mg/mL = 0.5 mL.

The nurse should plan to administer 0.5 mL of lorazepam oral solution to the client.

A. A client who has had prolonged diarrhea B. A client who has lactose intolerance C. A client who has had radiation therapy for head and neck cancer D. A client who has had a stroke E. A client who is 4 hr postoperative following a leg amputation under general anesthesia

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

Explanation

A. A client who has had prolonged diarrhea:

Prolonged diarrhea is not typically associated with an increased risk of aspiration during eating.

B. A client who has lactose intolerance:

Lactose intolerance primarily affects the ability to digest lactose-containing foods and does not directly increase the risk of aspiration.

C. A client who has had radiation therapy for head and neck cancer:

Radiation therapy to the head and neck can cause damage to the structures involved in swallowing, increasing the risk of aspiration.

D. A client who has had a stroke:

Stroke can affect the coordination of swallowing muscles, leading to dysphagia (difficulty swallowing) and an increased risk of aspiration.

E. A client who is 4 hr postoperative following a leg amputation under general anesthesia:

Postoperative clients under general anesthesia may experience impaired protective airway reflexes, making them prone to aspiration. It's important to monitor these clients closely during the initial recovery period.

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A nurse is working a night shift and caring for several clients at risk for falls. Which of the following actions should the nurse take? (Select all that apply.)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is ["0.5"]

Explanation

A nurse is caring for a group of clients. Which of the following clients should the nurse identify as having an increased risk for aspiration while eating? (Select all that apply.)

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

Explanation

A nurse is caring for a client who has heart failure and has been taking digoxin 0.25 mg daily. The client refuses breakfast and reports nausea. Which of the following actions should the nurse take first?

A nurse is obtaining informed consent from a client prior to surgery. Which of the following is necessary for informed consent to be valid? (Select all that apply.)

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A nurse is caring for a client following major spinal surgery who is reporting pain. The client's partner tells the nurse, "I wish I could do something to make my wife feel better." Which of the following responses should the nurse make?

A nurse is about to give a client a complete bed bath. Which of the following actions should the nurse take to maintain the client's privacy?

A provider is discharging a client with a prescription for home oxygen therapy. The nurse should reinforce which of the following instructions with the client and his family? (Select all that apply.)

A nurse's sibling had a diagnostic test at the nurse's facility. The sibling asks the nurse to look up the result in the computer. The nurse should identify which of the following as the reason for her decision about her sibling's request?

A nurse is caring for an older adult client who has dementia and whose family reports he gets up and wanders around at night. Which of the following actions should the nurse take?