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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Hypocalcemia- Vomiting and diarrhea can lead to fluid and electrolyte losses, but hypocalcemia is not a common finding in this scenario.
B. Hypermagnesemia- Hypermagnesemia is unlikely in the context of vomiting and diarrhea, as these conditions typically result in magnesium loss.
C. Hyperkalemia- Vomiting and diarrhea can lead to potassium loss, making hyperkalemia less likely.
D. Hypokalemia- Vomiting and diarrhea can cause potassium depletion, leading to hypokalemia. This electrolyte imbalance is commonly seen in clients with gastrointestinal losses.
Correct Answer is E,B,C,D,A
Explanation
First, the nurse should apply clean gloves (E) to maintain sterility and safety. Next, the nurse should disconnect the tube from the suction device (B), ensuring that the device is no longer actively working on the tube.
Before removing the tube, it is important to instill air into it (C); this helps clear any residual contents and minimizes the risk of aspiration. The nurse should then ask the client to take a deep breath (D), which helps close the epiglottis to prevent aspiration during the removal of the tube. Finally, the nurse can pinch and withdraw the tube (A), completing the process in a swift, steady motion to ensure comfort and safety for the client.
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