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An elderly client is hospitalized for the first time.

Which of the following actions ensures the safety of the client? (Select all that apply).

Keep call bell within the client’s reach.

Keep a dim light on at night.

Keep unnecessary furniture out of the way.

Keep all side rails up at all times.

Keep all lights off at night.

Answer and Explanation

Correct Answer : A,B,C

These actions ensure the safety of the client by reducing the risk of falls, confusion and injury.

Keeping a call bell within the client’s reach allows them to ask for help when needed.

Keeping a dim light on at night helps them orient themselves and see their surroundings.

Keeping unnecessary furniture out of the way prevents tripping and cluttering. Choice D is wrong because keeping all side rails up at all times can be considered a form of physical restraint, which is associated with many professional, legal and ethical challenges. Physical restraint should only be used as a last resort when other alternatives have failed or are not feasible. Keeping all side rails up can also increase the risk of injury if the client tries to climb over them.

Choice E is wrong because keeping all lights off at night can increase the risk of falls and confusion for the client.

Older adults may have impaired vision and cognition, and they may need to use the bathroom frequently at night. Keeping all lights off can make it difficult for them to find their way and increase their anxiety.

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Correct Answer is C

Explanation

This is an appropriately constructed goal statement for the client with COPD because it is specific, measurable, attainable, realistic and time-bound (SMART). It also addresses the client’s education needs and promotes self-care.

Choice A is wrong because it is not realistic or attainable for a client with COPD to have O2 saturation > 92% by discharge.

The normal range for O2 saturation is 95-100%, but clients with COPD may have lower levels due to chronic hypoxia.

Choice B is wrong because it is not a goal statement, but an intervention.

A goal statement should describe the expected outcome of the intervention, not the intervention itself.

Choice D is wrong because it is not measurable or time-bound.

A goal statement should have a clear indicator of how and when the outcome will be achieved.

A. “A nurse’s personal values are not considered when making ethical decisions.” B. “A nurse’s behaviors and actions are called values.” C. “It is important that the nurse is aware of the client’s values.” D. “Value clarification involves maintaining clinical competency.”. E. “Value clarification involves maintaining clinical competency.”.

Correct Answer is C

Explanation

This statement indicates an understanding of the ethical principle of respect for autonomy, which means that the nurse respects the client’s right to make their own decisions about their care and respects their values and beliefs.

Choice A is wrong because “A nurse’s personal values are not considered when making ethical decisions.” This statement contradicts the ethical principle of integrity, which means that the nurse acts in accordance with their personal and professional values and standards.

Choice B is wrong because “A nurse’s behaviors and actions are called values.” This statement confuses values with morals, which are the judgments about behaviors and actions based on personal or societal beliefs.

Choice D is wrong because “Value clarification involves maintaining clinical competency.” This statement confuses value clarification with professionalism, which involves maintaining clinical competency, accountability, and responsibility. Value clarification is a process of self-exploration and reflection that helps the nurse identify their own values and understand how they affect their ethical decisions.

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An elderly client is hospitalized for the first time. Which of the following actions ensures the safety of the client? (Select all that apply).

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse includes which of the following as an appropriately constructed goal statement for the client with COPD?

Correct Answer is C

Explanation

A nurse is teaching about values to a newly licensed nurse. Which of the following statements by the newly licensed nurse indicates an understanding?

Correct Answer is C

Explanation

A nurse is caring for a client whose family is in a state of disagreement over the care of their family member. The nurse should report the situation to which of the following facility personnel?

A charge nurse is providing an in-service to a group of nurses on the different levels of illness prevention. The nurse should include which of the following as an example of secondary prevention?

A client sees his primary care physician for complaints of fatigue. Bloodwork shows the client is anemic. Upon physical assessment, what signs would the provider expect to see? (Select all that apply)

Which of the following nursing diagnoses would typically NOT be associated with anemia?

Which thermoregulatory condition is an elderly person most at risk for?

A nurse is teaching a newly licensed nurse about informed consent. Which of the following should be included as a responsibility of the nurse in this process?

An elderly client is admitted to the hospital looking unkempt, with dirty clothing, and she smells of urine. The nurse is aware this may be:

An elderly client is hospitalized for the first time.

Which of the following actions ensures the safety of the client? (Select all that apply).