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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
This nursing diagnosis is typically not associated with anemia because anemia does not cause dehydration or loss of body fluids. Anemia is a condition in which the hemoglobin concentration or the number of red blood cells is lower than normal, resulting in decreased oxygen delivery to the tissues.
Choice A. Ineffective tissue perfusion is wrong because anemia can impair tissue perfusion by reducing the oxygen-carrying capacity of the blood.
Choice B. Activity intolerance is wrong because anemia can cause fatigue, weakness, and dyspnea on exertion due to inadequate oxygen supply to the muscles.
Choice D. Risk for decreased cardiac output is wrong because anemia can increase the risk of cardiac complications such as tachycardia, palpitations, angina, and heart failure due to increased cardiac workload and demand for oxygen.
Normal ranges for hemoglobin are 13.5 to 17.5 g/dL for men and 12 to 15.5 g/dL for women; normal ranges for hematocrit are 38.8 to 50% for men and 34.9 to 44.5% for women; normal ranges for red blood cell count are 4.7 to 6.1 million/mm3 for men and 4.2 to 5.4 million/mm3 for women; normal ranges for reticulocyte count are 0.5 to 1.5% of red blood cells.
Correct Answer is A
Explanation
The Nurse Practice Act is a law that outlines the legal scope of practice for nursing in each state. It defines the roles, functions, responsibilities and activities that a nurse is educated, competent and authorized to perform. The Nurse Practice Act also establishes the regulatory bodies that create and implement rules and regulations to protect the public.
Choice B. Nursing process is wrong because it is a systematic method of providing nursing care, not a legal document that defines the scope of practice.
Choice C. Code of Ethics is wrong because it is a set of principles that guide the moral and professional conduct of nurses, not a legal document that defines the scope of practice.
Choice D. Facility policies and procedures are wrong because they are specific guidelines for each healthcare organization, not a legal document that defines the scope of practice.
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