A nurse is assisting with the development of a plan of care for an older adult who is at risk for falls. Which of the following actions should the nurse contribute to the plan? (Select all that apply)

Keep the bed at a comfortable working height.

Administer a sedative at bedtime.

Keep a night light on in the client's room and bathroom.

Place the bedside table within the client's reach.

Lock the wheels on beds and wheelchairs during transfers.

Answer and Explanation

Correct Answer : C,D,E

Keeping a night light on in the client's room and bathroom can help reduce the risk of falls by improving visibility and orientation at night. Placing the bedside table within the client's reach can help reduce the risk of falls by making it easier for the client to access necessary items without having to get up and move around. Locking the wheels on beds and wheelchairs during transfers can help reduce the risk of falls by providing stability and preventing unwanted movement.

a. Keeping the bed at a comfortable working height is important for the nurse's comfort and safety while providing care, but it does not directly reduce the risk of falls for the client.

b. Administering a sedative at bedtime may help the client sleep, but it can also increase the risk of falls by causing drowsiness and disorientation.

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Correct Answer is D

Explanation

Having the client lie prone several times each day is an appropriate nursing intervention for a client who is 2 days postoperative following an above-the-knee amputation. Lying prone can help prevent hip ﬂexion contractures, which can occur after an above-the-knee amputation².

Elevating the foot of the bed is not an appropriate intervention for a client who is 2 days postoperative following an above-the-knee amputation.

Encouraging sitting up as much as possible is not an appropriate intervention for a client who is 2 days postoperative following an above-the-knee amputation.

Elevating the stump on a pillow is not an appropriate intervention for a client who is 2 days postoperative following an above-the-knee amputation.

A. Obtain a throat culture specimen. B. Perform a complete blood count. C. Check the client's temperature. D. Administer an oral analgesic.

Correct Answer is C

Explanation

The first action the nurse should perform is to check the client's temperature. A headache and stiﬀ neck can be symptoms of meningitis, which is an inﬂammation of the membranes surrounding the brain and spinal cord. Meningitis can be caused by a bacterial or viral infection and is often accompanied by a fever. Checking the client's temperature can help determine if the client has a fever and if further evaluation for meningitis is necessary.

Obtaining a throat culture specimen is not the first action the nurse should take.

Performing a complete blood count is not the first action the nurse should take.

Administering an oral analgesic is not the first action the nurse should take.

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A nurse is assisting with the development of a plan of care for an older adult who is at risk for falls. Which of the following actions should the nurse contribute to the plan? (Select all that apply)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who is 2 days postoperative following an above-the-knee amputation. Which of the following is an appropriate nursing intervention for the client at this time?

Correct Answer is D

Explanation

A nurse at a community health clinic is caring for a client who reports a headache and stiﬀ neck. Which of the following actions should the nurse perform first?

Correct Answer is C

Explanation

A nurse is assisting with the development of a plan of care for an older adult who is at risk for falls. Which of the following actions should the nurse contribute to the plan? (Select all that apply)

A nurse is caring for a client who is unconscious following a stroke. Which of the following nursing interventions is of highest priority?

A nurse is collecting data from a client who has an exacerbation of gout. Which of the following findings should the nurse expect? (Select all that apply.)

A nurse is collecting data from a client following the application of a leg cast for the treatment of a fracture. Which of the following findings should the nurse expect to find first if the cast is too tight?

A nurse is caring for a client who is postoperative following a right total hip arthroplasty. In which of the following positions should the nurse place the client's right leg?

A nurse is collecting data from a client who has a traumatic head injury. Which of the following findings should the nurse report to the provider immediately?

A nurse is reinforcing teaching with a client who has a knee injury. When describing range-of-motion exercises, the nurse should explain that the knee is which of the following types of joints?

While collecting data from a client who has a cast on his right leg, a nurse locates an area on the cast that feels warm to the touch. Which of the following findings should the nurse identify as a complication to the client's condition?