A nurse is assisting in creating a plan to reduce environmental stressors for clients in an acute care unit.
Which of the following actions should the nurse include in the plan?

Offer the clients many choices regarding care.

Restrict the number of visitors for clients.

Assign different nurses to provide care for clients each day.

Turn on loud music in client care areas.

Answer and Explanation

The Correct Answer is B

This action can help to reduce environmental stressors for clients in an acute care unit by limiting noise, crowding, and potential sources of infection.

Visitors should be allowed according to the client’s preference and condition, but excessive or inappropriate visitors should be discouraged.

Choice A is wrong because offering the clients many choices regarding care can increase their stress and anxiety, especially if they are confused, overwhelmed, or unable to make decisions.

The nurse should respect the client’s autonomy and preferences, but also provide guidance and education to help them make informed choices.

Choice C is wrong because assigning different nurses to provide care for clients each day can reduce the continuity and quality of care, as well as the trust and rapport between the client and the nurse.

The nurse should strive to provide consistent and individualized care for each client and establish a therapeutic relationship.

Choice D is wrong because turning on loud music in client care areas can increase environmental stressors for clients in an acute care unit by creating noise pollution, disrupting sleep, and interfering with communication.

The nurse should maintain a quiet and calm environment for the clients and use music only if it is soothing and requested by the client.

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Correct Answer is D

Explanation

The correct answer is D. Using two gloved fingers to open the client’s mouth for cleaning.

Choice A rationale:

Lowering the side rail on the side of the bed where the AP will stand is necessary for safe access to the client. However, the AP should ensure the opposite side rail is up to prevent the client from falling.

Choice B rationale:

Using an oral care sponge swab moistened with cool water is an appropriate method for cleaning the mouth of an unconscious client. It helps maintain oral hygiene and comfort.

Choice C rationale:

Wearing clean gloves is essential for infection control and is a standard practice when performing mouth care to protect both the client and the caregiver.

Choice D rationale:

Using two gloved fingers to open the client’s mouth is not recommended as it can cause injury to the caregiver if the client bites down reflexively. Instead, a padded tongue blade should be used to gently open the mouth.

A. A client is unable to afford the physical therapy that the provider recommends. B. A client reports being dissatisfied with the temperature of the meals provided. C. A client’s visitor becomes dizzy and faints in the client’s room. D. A client receives burns from a heating pad. E. A client becomes disoriented and falls out of bed.

Correct Answer is ["C","D","E"]

Explanation

The correct answer is choice C, D, and E.

Choice A rationale:A client being unable to afford physical therapy is a financial issue, not an incident that affects patient safety or care quality. This situation should be addressed through social services or financial counseling, not an incident report.

Choice B rationale:A client being dissatisfied with meal temperature is a service quality issue, not a safety incident. This should be reported to the dietary department or patient services for resolution, not through an incident report.

Choice C rationale:A client’s visitor becoming dizzy and fainting in the client’s room is an incident that affects the safety of the visitor. An incident report should be completed to document the event, the visitor’s condition, and any actions taken to provide care or prevent future occurrences.

Choice D rationale:A client receiving burns from a heating pad is a safety incident that directly affects the client’s well-being. An incident report should be completed to document the injury, the circumstances leading to the burn, and any immediate care provided.

Choice E rationale:A client becoming disoriented and falling out of bed is a significant safety incident. An incident report should be completed to document the fall, the client’s condition, and any interventions implemented to prevent future falls.

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A nurse is assisting in creating a plan to reduce environmental stressors for clients in an acute care unit. Which of the following actions should the nurse include in the plan?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse observes assistive personnel (AP) perform mouth care for a client who is unconscious. Which of the following actions by the AP requires intervention by the nurse?

Correct Answer is D

Explanation

A nurse is caring for a group of clients. For which of the following situations should the nurse complete an incident report? (Select all that apply.).

Correct Answer is ["C","D","E"]

Explanation

A nurse is reviewing the laboratory results for a client who reports vomiting and diarrhea for 2 days. Which of the following laboratory findings should the nurse expect?

A nurse is caring for a client who has hearing loss. Which of the following actions should the nurse take to promote communication?

A nurse is assisting a client who is 4 hr postoperative to get out of bed. The client states, “Do not touch me! I can get up by myself.” Which of the following responses should the nurse make?

A nurse is disinfecting the room of a client who has a Clostridium difficultiesinfection. Which of the following solutions should the nurse use?

A nurse on a medical-surgical unit is collecting data from a client who is postoperative following abdominal surgery. The client’s BP was 126/72 mm Hg 15 min ago. The nurse now finds that the client’s BP is 176/96 mm Hg. Which of the following actions should the nurse take?

A nurse is assisting with the admission of a client. Which of the following statements should the nurse make to demonstrate the principle of advocacy?

A nurse is assisting with scoliosis screenings for students at a public school. Which of the following findings should the nurse recognize as an indication of scoliosis?

A nurse is caring for a young adult client who is postoperative and requires physical therapy, pain management, and dietary advancement. The nurse enters the client’s room and finds them dressing and stating that they are going home. Which of the following actions should the nurse take?

A nurse is assisting in creating a plan to reduce environmental stressors for clients in an acute care unit.
Which of the following actions should the nurse include in the plan?