The nurse prepares to leave the room after completing a client assessment. What action(s) should a nurse plan to take to promote safety before leaving a client's room? Select all that apply.

Offer comfort measures to the client

Verify that two bedside rails are raised

Ensure the bed is in the lowest position

Thank the client before leaving the room

Check that the bed is in the locked position

Answer and Explanation

Correct Answer : A,C,E

A. Offer comfort measures to the client: Providing comfort measures, such as adjusting pillows, blankets, or positioning, helps prevent discomfort and reduces the risk of the client attempting unsafe movements, promoting overall safety.

B. Verify that two bedside rails are raised: Raising only two bedside rails is not considered a safe practice for preventing falls. Safety guidelines recommend either following facility policy for rail use or using alternative safety measures rather than arbitrarily raising two rails.

C. Ensure the bed is in the lowest position: Keeping the bed in the lowest position reduces the risk of injury if a client attempts to get out of bed independently, helping prevent falls and enhancing safety.

D. Thank the client before leaving the room: While expressing courtesy is important for rapport and communication, it does not directly contribute to the physical safety of the client.

E. Check that the bed is in the locked position: Locking the bed prevents unintentional movement, especially when the client attempts to get in or out, which is essential for fall prevention and safety.

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Correct Answer is A

Explanation

A. Loss of appetite: Subjective data are based on the client’s personal experiences, feelings, and perceptions. Loss of appetite is reported by the client and reflects their subjective experience.

B. Wound appearance: The appearance of a wound is observable and measurable, making it objective data that the nurse can assess through inspection.

C. Heart rate: Heart rate is measured using vital signs and instruments, making it objective data rather than a subjective report from the client.

D. Cyanosis: Cyanosis is a visible physical sign indicating decreased oxygenation. It is observed by the nurse, so it is considered objective data.

A. Both the bell and diaphragm are used interchangeably for all types of sounds and pitches B. The bell is used for high-pitched sounds, while the diaphragm is used for low-pitched sounds C. The diaphragm is used for high-pitched, like bowel sounds, while the bell is for low-pitched sounds D. The diaphragm is used for softer sounds, like a murmur, while the bell is used for louder sounds

Correct Answer is C

Explanation

A. Both the bell and diaphragm are used interchangeably for all types of sounds and pitches: The bell and diaphragm have distinct functions and are not interchangeable; each is designed to optimally detect specific sound frequencies.

B. The bell is used for high-pitched sounds, while the diaphragm is used for low-pitched sounds: This is incorrect; the bell is designed for low-pitched sounds, and the diaphragm is used for high-pitched sounds.

C. The diaphragm is used for high-pitched, like bowel sounds, while the bell is for low-pitched sounds: The diaphragm efficiently detects high-frequency sounds such as breath sounds, bowel sounds, and normal heart sounds, while the bell is more sensitive to low-frequency sounds like heart murmurs or bruits.

D. The diaphragm is used for softer sounds, like a murmur, while the bell is used for louder sounds: This reverses their functions; the bell is better suited for soft, low-pitched sounds, whereas the diaphragm captures louder, high-pitched sounds.

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The nurse prepares to leave the room after completing a client assessment. What action(s) should a nurse plan to take to promote safety before leaving a client's room? Select all that apply.

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Naxlex Comprehensive Predictor Exams

Which information obtained during a history and physical examination should the nurse document as subjective data?

Correct Answer is A

Explanation

Which statement describes the function of the bell and diaphragm of a stethoscope?

Correct Answer is C

Explanation

Exhibits Review the electronic health record. Which finding(s) should the nurse identify as subjective data? Select all that apply.

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During a client interview, which is an example of an active listening technique a nurse can use to improve communication?

A nurse is conducting several health assessments. Which action(s) should the nurse delegate to the unlicensed assistive personnel (UAP)? Select all that apply.

The nurse prepares to leave the room after completing a client assessment. What action(s) should a nurse plan to take to promote safety before leaving a client's room? Select all that apply.

The nurse completes training in administering chemotherapy before transferring to an oncology unit to ensure they can care for those clients safely. Which ethical principle has the nurse demonstrated?

The nurse is caring for a client diagnosed with type 1 diabetes two months ago. The client reports being admitted to the hospital several times due to hypoglycemia. When educating the client about their disease process before discharge, which information should the nurse prioritize?

A nurse is documenting findings following the examination of a client. Which should the nurse include as part of the general survey?