A nurse is assisting with a quality improvement project to decrease client falls. Which of the following activities should the nurse perform?

Document an incident report in a client's medical record.

Notify the provider if a client fails

Assist with the care of a client who has fallen.

Collect data about each fall

Answer and Explanation

The Correct Answer is D

A. Document an incident report in a client's medical record: Incident reports are essential for internal documentation but should not be placed in the client’s medical record. Including them in the medical record can lead to legal complications. This action addresses individual events rather than contributing to systematic quality improvement efforts.

B. Notify the provider if a client falls: Notifying the provider about a fall is a necessary clinical step to ensure immediate evaluation and care for the client. However, simply informing the provider does not contribute directly to a quality improvement initiative aimed at analyzing and reducing overall fall rates.

C. Assist with the care of a client who has fallen: Providing immediate care after a fall is crucial to ensure client safety and manage injuries. However, assisting after the fall focuses on acute clinical response rather than on proactive measures to identify trends and reduce the incidence of future falls.

D. Collect data about each fall: Collecting data is a fundamental part of quality improvement projects. By systematically gathering information on when, where, and how falls occur, patterns can be identified, leading to the development of targeted interventions aimed at preventing future incidents.

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Correct Answer is C

Explanation

A. Position the client's finger above their heart: The finger should be positioned below the level of the heart to encourage blood flow, making it easier to obtain a sufficient blood sample for testing. Elevating the finger would decrease blood flow and make collection more difficult.

B. Apply sterile gloves prior to performing the test: Clean, non-sterile gloves are sufficient for routine blood glucose monitoring. Sterile gloves are not necessary unless performing procedures that require a sterile environment, such as surgery or central line dressing changes.

C. Puncture the side of the client's finger: The sides of the fingertips have fewer nerve endings compared to the pads, making the procedure less painful. Additionally, puncturing the side helps promote better blood flow and reduces the risk of bruising and soreness.

D. Milk the finger site: Milking or squeezing the finger excessively can cause hemolysis or contamination of the blood sample with tissue fluid, leading to inaccurate glucose readings. Gentle pressure may be used if needed, but forceful milking should be avoided.

A. Weight B. Potassium C. Pedal pulses D. Temperature E. Orientation F. Chest x-ray G. Urine output

Correct Answer is ["A","C","F","G"]

Explanation

Weight: The client has gained over 1 kg (about 2.2 lb) within a week, suggesting fluid retention. In combination with crackles, edema, and cardiomegaly, this weight gain indicates worsening heart failure and requires prompt intervention to manage fluid overload.
Potassium: A potassium level of 3.5 mEq/L is at the lower limit of normal. While it should be monitored, it does not independently demand immediate action unless it trends lower or the client shows symptoms of hypokalemia.
Pedal pulses: Pedal pulses have decreased from 2+ to 1+, and the extremities are now cool. These changes suggest compromised peripheral circulation, likely related to decreased cardiac output, and warrant further assessment and management.
Temperature: The client’s temperature is within the normal range. There are no signs of fever or hypothermia, so this finding does not require immediate action based on the current clinical data.
Orientation: The client remains alert and oriented, with no noted decline in mental status. Therefore, orientation findings are stable and do not necessitate further immediate intervention.
Chest x-ray: The presence of cardiomegaly on chest x-ray suggests worsening heart failure or fluid overload. This finding is significant and requires timely medical evaluation and management to prevent further cardiac decompensation.
Urine output: The client’s urine output has drastically decreased from 520 mL/hr to 160 mL in 8 hours, indicating impaired renal perfusion or acute kidney injury. This is a critical finding and requires immediate provider notification and intervention.

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A nurse is assisting with a quality improvement project to decrease client falls. Which of the following activities should the nurse perform?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is performing blood glucose monitoring on a client. Which of the following actions should the nurse take?

Correct Answer is C

Explanation

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Correct Answer is ["A","C","F","G"]

Explanation

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