A charge nurse is observing a newly licensed nurse care for a client who is at risk for falls. Which of the following findings should the nurse identify as a risk factor for falls?
Positions the bedside table close to the client
Keeps the client's bed in the low position
Attaches the call light to the side rail of the client's bed
Instructs the client to wear their own socks to the bathroom
The Correct Answer is D
Choice A: This is incorrect because positioning the bedside table close to the client can help them reach their personal items and reduce the need to get out of bed.
Choice B: This is incorrect because keeping the client's bed in the low position can prevent injuries in case of a fall and make it easier for the client to get in and out of bed.
Choice C: This is incorrect because attaching the call light to the side rail of the client's bed can ensure that the client can access it easily and call for assistance when needed.
Choice D: This is correct because instructing the client to wear their own socks to the bathroom can increase the risk of slipping and falling. The client should wear non-skid footwear or slippers when walking.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A: This is incorrect because sore throat is not a finding that the nurse should report to the provider. Sore throat is a common and expected complication of bronchoscopy due to irritation from the endoscope. The nurse should provide oral care and offer ice chips or lozenges to soothe the throat.
Choice B: This is incorrect because blood pressure 110/78 mm Hg is not a finding that the nurse should report to the provider. Blood pressure 110/78 mm Hg is within the normal range and does not indicate any adverse effects from bronchoscopy. The nurse should monitor the vital signs and oxygen saturation of the client.
Choice C: This is correct because facial edema is a finding that the nurse should report to the provider. Facial edema can indicate an allergic reaction, airway obstruction, or mediastinal emphysema, which are serious and potentially life-threatening complications of bronchoscopy. The nurse should assess the airway, breathing, and circulation of the client and administer oxygen and medications as prescribed.
Choice D: This is incorrect because presence of gag reflex is not a finding that the nurse should report to the provider. Presence of gag reflex is an expected outcome of bronchoscopy, indicating that the anesthesia has worn off and the client can resume oral intake. The nurse should check the gag reflex before offering any food or fluids to the client.
Correct Answer is B
Explanation
Choice A reason: Blurred vision is not an expected side effect of digoxin, but a sign of digoxin toxicity, which requires immediate medical attention.
Choice B reason: This is the correct answer because digoxin can cause hypokalemia (low potassium levels), which increases the risk of digoxin toxicity. Therefore, clients taking digoxin need to have their potassium levels monitored regularly and consume foods rich in potassium.
Choice C reason: Antacids can interfere with the absorption of digoxin and reduce its effectiveness. Clients taking digoxin should avoid taking antacids within two hours of taking the medication.
Choice D reason: Weighing oneself every other day is not related to digoxin therapy, but to fluid balance. Clients with heart failure, who are often prescribed digoxin, need to monitor their weight daily and report any significant changes to their health care provider.
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