The RN performs an admission assessment and determines the client is a fall risk. What is a priority nursing intervention for this client?

Provide a walker.

Place a chair on either side of the bed.

Provide a cane.

Place a fall risk wrist band on the client.

Answer and Explanation

The Correct Answer is D

This is because a fall risk wristband alerts the staff and other caregivers that the client is at risk of falling and needs extra precautions and supervision. A walker, a cane, or a chair on either side of the bed are not priority interventions for a fall risk client, as they do not address the root cause of the problem or prevent potential falls.

Choice A is wrong because a walker may not be appropriate for the client’s condition or mobility level, and it may pose a tripping hazard if not used correctly.

Choice B is wrong because placing a chair on either side of the bed may limit the client’s access to the bed or the bathroom, and it may also create clutter and obstruction in the room.

Choice C is wrong because a cane may not provide enough stability or support for the client, and it may also be difficult to use in narrow spaces or on slippery surfaces.

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Correct Answer is A

Explanation

This is an example of secondary prevention, which is the action taken to stop the progress of the disease at the initial stage and prevent complications. An echocardiogram can help diagnose the severity and cause of heart failure and guide the treatment plan.

A client who has a family history of breast cancer and is scheduled for a mammogram is an example of secondary prevention. Secondary prevention is early detection of a disease before it progresses. Secondary prevention can include screenings and other forms of diagnostic tests.

This is an example of tertiary prevention, which is the action taken to stop the progress of the disease at the initial stage and prevent complication. An echocardiogram can help diagnose the severity and cause of heart failure and guide the treatment plan.

Choice C is wrong because it is not an example of any level of prevention.

A client who is asymptomatic is not scheduled for a series of tests because there is no indication of any disease or risk factor.

Choice D is wrong because it is an example of primary prevention, which is the action taken to prevent the development of disease.

A client who is scheduled to receive an influenza vaccination is protected from getting infected by the virus and developing flu-related complications.

A. Red, sore tongue. B. Pica. C. Splenomegaly and Jaundice. D. Paresthesias.

Correct Answer is C

Explanation

Splenomegaly and jaundice are signs of hemolytic anemia, a disorder in which red blood cells are destroyed faster than they are made.

Splenomegaly is an enlargement of the spleen, which may trap and destroy healthy red blood cells. Jaundice is a yellowing of the skin and eyes caused by the buildup of bilirubin, a waste product of hemoglobin breakdown. Choice A is wrong because red, sore tongue is a sign of vitamin B12 deficiency anemia, not hemolytic anemia.

Choice B is wrong because pica is a craving for nonfood items, such as ice, dirt, or starch. It is a sign of iron deficiency anemia, not hemolytic anemia. Choice D is wrong because paresthesias are sensations of tingling, numbness, or prickling in the hands or feet. They are a sign of pernicious anemia, a type of vitamin B12 deficiency anemia, not hemolytic anemia.

Normal ranges for red blood cell count are 4.5 to 5.9 million cells per microliter for men and 4.1 to 5.1 million cells per microliter for women. Normal ranges for hemoglobin are 13.5 to 17.5 grams per deciliter for men and 12.0 to 15.5 gramsper deciliter for women. Normal ranges for bilirubin are 0.1 to 1.2 milligrams per deciliter for adults.

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The RN performs an admission assessment and determines the client is a fall risk. What is a priority nursing intervention for this client?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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?

Correct Answer is A

Explanation

Signs of hemolytic anaemias include:

Correct Answer is C

Explanation

The nurse does not turn a client every two hours as ordered, and the client develops a pressure injury. What legal concept applies?

The RN performs an admission assessment and determines the client is a fall risk. What is a priority nursing intervention for this client?

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