A nurse is collecting data from a client who has an acute condition. Which of the following findings should the nurse identify as increasing the risk for potential client injuries?
Hearing acuity intact
Oriented to person only
Full range of motion bilateral lower extremities
Ability to use call light
The Correct Answer is B
A) Hearing acuity intact - Intact hearing acuity does not directly increase the risk for potential client injuries.
B) Oriented to person only - Being oriented to person only may indicate confusion or disorientation, which can increase the risk for potential client injuries due to impaired decision-making or awareness of surroundings.
C) Full range of motion bilateral lower extremities - Having a full range of motion in the lower extremities does not directly increase the risk for potential client injuries.
D) Ability to use call light - The ability to use a call light indicates the client's ability to seek assistance, which reduces the risk for potential client injuries.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A) To an employer for a pre-employment screening - Health information should not be disclosed to an employer without the client's written consent, as it violates the client's right to privacy and confidentiality.
B) To an insurance agency in regard to a life insurance policy - Health information should not be disclosed to an insurance agency without the client's written consent, as it violates the client's right to privacy and confidentiality.
C) To a family member when the client is not available - Health information should only be disclosed to family members with the client's written consent or in situations where it is necessary for the client's care or safety.
D) To a medical interpreter service on behalf of a client - Health information can be disclosed to a medical interpreter service without the client's written consent to facilitate communication between the client and healthcare providers while maintaining confidentiality.
Correct Answer is C
Explanation
A. Verifying the bilirubin level of the tube contents is not a reliable method for confirming tube placement and may not provide accurate information.
B. Auscultating for air insufflation can help detect tube placement in the respiratory tract but may not reliably confirm placement in the gastrointestinal tract.
C. Requesting a chest x-ray is the most reliable method for confirming the placement of a feeding tube, as it allows visualization of the tube's position relative to anatomical landmarks.
D. Checking the pH level of gastric contents can help differentiate between gastric and respiratory placement but may not provide definitive confirmation of tube placement.
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