The nurse is developing the plan of care for a patient who is unable to bear weight on the right foot. The patient requires assistance to get out of bed and has recently fallen. Which of the following nursing diagnosis would be most appropriate for this patient?

Acute pain

Risk for injury

Activity Intolerance

Toileting self-care deficit

Answer and Explanation

The Correct Answer is B

A. Acute pain: This diagnosis might be relevant if the patient has pain, but it does not address the main concern of mobility and risk related to recent falls.

B. Risk for injury: This is the most appropriate diagnosis as the patient’s inability to bear weight and recent falls increase their risk of further injury.

C. Activity Intolerance: While the patient may have activity intolerance, the more pressing concern related to their recent falls and inability to bear weight is the risk for injury.

D. Toileting self-care deficit: This diagnosis might be relevant if there were specific issues with toileting, but it is not the most appropriate for the general risk of injury due to recent falls.

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

Explanation

A. Scrub the stem of the ampule with an antimicrobial wipe. This is not necessary because the stem of the ampule is broken and is not typically touched with hands or contaminated. The main concern is to prevent any glass from falling into the medication.

B. Break the stem of the ampule away from the body. Breaking the stem away from the body helps to prevent any shards of glass from falling into the medication or causing injury.

C. Attach a filter needle to the syringe. A filter needle is used to prevent any glass particles from entering the syringe when drawing up the medication from an ampule.

D. Tap the stem of the ampule. Tapping the stem may help remove any bubbles but is not a standard practice in ampule preparation.

E. Wrap the stem of the ampule with a sterile gauze pad. Wrapping the stem with a sterile gauze pad provides protection from glass shards and helps prevent injury when breaking the ampule.

A. Small muscle twitching. B. An increase in temperature. C. Difficult to arouse. D. An increase in pulse rate.

Correct Answer is C

Explanation

A. Small muscle twitching. Small muscle twitching is more common during REM sleep, not Stage IV NREM sleep.

B. An increase in temperature. Stage IV NREM sleep is associated with stable body temperature rather than an increase.

C. Difficult to arouse. Stage IV NREM sleep is known as deep sleep, and individuals are indeed difficult to arouse during this stage.

D. An increase in pulse rate. Stage IV NREM sleep typically features a stable or decreased pulse rate, not an increase.

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The nurse is developing the plan of care for a patient who is unable to bear weight on the right foot. The patient requires assistance to get out of bed and has recently fallen. Which of the following nursing diagnosis would be most appropriate for this patient?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is preparing a prescribed medication for a client from an ampule. Which of the following actions should the nurse take? Select all that apply.

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

Explanation

The nurse is assessing the vital signs of a sleeping patient at 0400 a.m. and notes the patient is experiencing stage IV non-rapid eye movement (NREM) sleep. The nurse should expect which of the following findings?

Correct Answer is C

Explanation

The home health nurse is visiting with a client with terminal cancer whose partner has become the primary caregiver. The partner states, "Maybe I will lose weight since I rarely have time to eat." Which of the following responses should the nurse make?

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