When entering a client's room, the nurse observes the client holding up an arm and coughing non-productively into the upper sleeve. Which action should the nurse take?

Provide a box of tissues for the client to use when coughing.

Assist the client in changing into a fresh hospital gown.

Teach the client to cover the mouth with hands when coughing.

Obtain face masks for staff to wear upon entering the room.

Answer and Explanation

The Correct Answer is A

A. Providing tissues is a helpful measure for clients to use when they need to cough or sneeze. It promotes good hygiene by allowing the client to dispose of respiratory secretions properly. However, this choice does not address the immediate concern of how the client is currently coughing and the potential for spreading infection.
B. Assisting the client with a gown change may be necessary if their current gown is soiled. However, this action does not directly address the infection control issue or the client’s method of coughing. Changing the gown is secondary to addressing proper coughing techniques and infection control.
C. Teaching clients to cover their mouth with their hands is not ideal, as it can spread germs if the hands are not washed immediately afterward. Instead, clients should be taught to cough into a tissue or their elbow (not the sleeve) to minimize the spread of germs. This is a crucial component of infection control and helps reduce the risk of transmission.
D. Providing face masks for staff is an important measure in infection control, especially if the client has a respiratory illness. However, it does not address the client's current coughing technique or teach the client how to prevent the spread of infection through their own actions.

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Correct Answer is A

Explanation

A. The Z-track technique helps to prevent medication from leaking into the subcutaneous tissue and minimizes irritation by sealing the medication in the muscle. This is especially important for medications that are known to cause irritation or staining, such as iron supplements or some antipsychotics
B. The length of the needle is not directly related to the use of the Z-track technique. The Z-track method is used to minimize irritation and ensure that the medication is deposited in the muscle rather than leaking into the subcutaneous tissue.
C. The reason for using the Z-track technique is related to preventing irritation and ensuring proper medication delivery, rather than simply following a prescription.
D. The volume of medication is not the primary reason for using the Z-track technique. While the Z-track method can be used for administering larger volumes of medication, the technique's primary purpose is to prevent leakage and reduce tissue irritation.

A. Recent serum hemoglobin level of 16 g/dL (160 g/L). B. Opioid analgesic received one hour ago. C. Expressed feelings of depression. D. Stooped posture with a steady gait.

Correct Answer is B

Explanation

A. A serum hemoglobin level of 16 g/dL (160 g/L) is within the normal reference range for adults (14 to 18 g/dL). Hemoglobin levels that are within the normal range generally do not indicate a direct risk for falls. Low hemoglobin (anemia) could potentially increase fall risk due to fatigue or dizziness, but a normal level is not a risk factor for falls.
B. Opioid analgesics are known to have side effects such as sedation, dizziness, and impaired motor coordination, which can increase the risk of falls. The recent administration of opioids makes this a significant factor in assessing fall risk, as the client may still be experiencing side effects from the medication that could impair their balance or cognitive function.
C. Depression can contribute to fall risk in several ways, including reduced motivation to engage in activities, decreased physical strength, and impaired attention. However, while important to address, depression alone is not as immediate or direct a risk factor for falls compared to factors like recent medication side effects or actual physical impairments.
D. Stooped posture may be indicative of issues such as musculoskeletal problems or balance difficulties. However, if the client has a steady gait, it suggests that despite the stooped posture, their current ability to walk is stable. The stooped posture alone might increase fall risk over time, but it is not as directly related to the immediate risk of falls as recent medication effects.

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When entering a client's room, the nurse observes the client holding up an arm and coughing non-productively into the upper sleeve. Which action should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is teaching another nurse about the administration of medication using the Z track technique. Which is the primary reason for using a Z track technique to administer a medication?

Correct Answer is A

Explanation

Which assessment data reflects the need for the nurse to include the problem, "Risk for falls" in a client's plan of care? Reference Range: Hemoglobin [14 to 18 g/dL (140 to 180 g/L)]

Correct Answer is B

Explanation

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