A nurse in a rehabilitation unit is assessing a group of clients who have a traumatic brain injury. The nurse should identify that which of the following clients requires a priority referral?

A client who needs assistance when ambulating.

A client who consistently has difficulty using utensils while eating.

A client who has expressive aphasia.

A client who consistently coughs after drinking liquids.

Answer and Explanation

The Correct Answer is C

Choice A rationale:

A client who needs assistance when ambulating is an important consideration for care, but it does not necessarily require a priority referral. The nurse can assess the client's mobility and coordinate assistance within the rehabilitation unit as needed.

Choice B rationale:

A client who consistently has difficulty using utensils while eating is a concern for occupational therapy or speech therapy, but it is not an immediate priority. The client's difficulty with eating utensils can be addressed through therapeutic interventions within the rehabilitation setting.

Choice C rationale:

A client who has expressive aphasia requires a priority referral because this indicates potential communication difficulties that could hinder the client's ability to express needs, understand instructions, and participate in therapy. Expressive aphasia can impact the client's overall rehabilitation progress and safety.

Choice D rationale:

A client who consistently coughs after drinking liquids might require assessment and intervention, but it does not present an immediate priority. The nurse can address this concern within the rehabilitation unit and collaborate with the interdisciplinary team as needed.

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Correct Answer is B

Explanation

Choice A rationale:

Moving the client using a slider board might be appropriate for transferring clients with relatively lower weight and mobility challenges. However, in this scenario, where the client weighs 136 kg (300 lb), a more advanced transfer method is necessary to ensure the safety of both the client and the healthcare providers.

Choice B rationale:

Using an air-assisted transfer device is suitable for transferring clients with higher weight, as it helps reduce friction and strain during the transfer process. This approach ensures a smoother transfer and minimizes the risk of injury to both the client and the assistive personnel.

Choice C rationale:

Raising the bed to 5 cm (2 in) above the level of the stretcher might not provide enough clearance for a safe transfer. Additionally, the use of assistive devices is more appropriate for transferring clients with significant weight, rather than relying solely on adjusting the bed height.

Choice D rationale:

Positioning the head of the bed at 25° prior to the transfer is not directly relevant to the process of transferring a client from a bed to a stretcher. The focus should be on using appropriate equipment and techniques for safe and efficient transfer, especially considering the client's weight.

A. Send the unused portion to the pharmacy. B. Have a second nurse verify disposal of the unused portion. C. Keep the unused portion in the client's medication drawer. D. Return the unused portion to the locked narcotics storage location.

Correct Answer is D

Explanation

When handling an unused portion of an oral opioid analgesic after administration, the nurse should take the following action:

D) Return the unused portion to the locked narcotics storage location.

Returning the unused portion to the locked narcotics storage location is a crucial step to ensure proper control and documentation of controlled substances like opioids. It helps prevent diversion and ensures the security and accountability of these medications.

Options A, B, and C are not appropriate:

A) Sending the unused portion to the pharmacy is not typically the responsibility of the nurse, and it may not be a practical or safe option for controlled substances.

B) Having a second nurse verify disposal of the unused portion is not a standard practice for oral medication administration.

C) Keeping the unused portion in the client's medication drawer is not an appropriate method of handling unused controlled substances, as it lacks the necessary security and accountability measures.

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A nurse in a rehabilitation unit is assessing a group of clients who have a traumatic brain injury. The nurse should identify that which of the following clients requires a priority referral?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is preparing to transfer a client who weighs 136 kg (300 lb) from a bed to a stretcher with the aid of an assistive personnel (AP). Which of the following actions should the nurse take?

Correct Answer is B

Explanation

A nurse is preparing to administer an oral opioid analgesic to a client. Which of the following actions should the nurse take when handling an unused portion of the medication after administration?

Correct Answer is D

Explanation

A nurse is reviewing data in a client's medical record. Which of the following information should the nurse expect to find in the discharge summary section?

A nurse is teaching the family of a client who has a terminal illness about end-of-life care. Which of the following statements by a family member indicates an understanding of the teaching?

A nurse is setting up a sterile field prior to changing a client's dressing. Which of the following actions should the nurse take?

A nurse is planning a community education session about the basic principles of first aid. Which of the following teaching strategies should the nurse implement for a group of adult learners in a community setting?

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A nurse is admitting a client who has rubella. Which of the following actions should the nurse plan to take?

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