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

Answer and Explanation

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.

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Correct Answer is B

Explanation

Choice A reason: Pupillary dilation is not a sign of opioid toxicity, but rather of opioid withdrawal or stimulant overdose. Opioid toxicity causes pupillary constriction or miosis.

Choice B reason: Hypotension is a sign of opioid toxicity sign of opioid toxicity, as opioids can depress the central nervous system and reduce cardiac output and peripheral resistance.

Choice C reason: Chest pain is not a sign of opioid toxicity, but rather of cardiac ischemia or infarction, which can be caused by cocaine or other stimulants.

Choice D reason: Diaphoresis is not a sign of opioid toxicity, but rather of opioid withdrawal or hyperthermia, which can be caused by ecstasy or other stimulants.

A. 1) Aspirate by pulling back on the plunger and inject the medication. B. 2) Use the nondominant hand to pull the skin and subcutaneous tissue 2.5 cm (1 in) laterally. C. 3) Remove the needle and release the tissue. D. 4) Put on gloves and cleanse the site with an antiseptic swab. E. 5) Insert the needle into the muscle.

Correct Answer is d,b,e,a,c

Explanation

The sequence the nurse should use to administer the medication using the Z-track technique is:

- Step 1: Put on gloves and cleanse the site with an antiseptic swab.

- Step 2: Use the nondominant hand to pull the skin and subcutaneous tissue 2.5 cm (1 in) laterally.

- Step 3: Insert the needle into the muscle.

- Step 4: Aspirate by pulling back on the plunger and inject the medication.

- Step 5: Remove the needle and release the tissue.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is collecting data from a client who is experiencing opioid toxicity. Which of the following findings should the nurse expect?

Correct Answer is B

Explanation

Correct Answer is d,b,e,a,c

Explanation

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