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

Answer and Explanation

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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Correct Answer is B

Explanation

A) Apply cornstarch powder to the perineal area. - Cornstarch powder may increase the risk of infection and should be avoided in the perineal area, especially for clients with fecal incontinence.
B) Place a moisture barrier ointment over the perineal area. - Moisture barrier ointment helps protect the skin from irritation and breakdown caused by fecal incontinence.
C) Turn the client every 4 hr. - Turning the client every 2 hours is recommended for preventing pressure ulcers, but it does not specifically address fecal incontinence.
D) Cleanse the perineal area with povidone-iodine solution. - Povidone-iodine solution is not typically used for routine perineal care and may irritate the skin.

A. Administering vaginal cream to a client who has a vaginal infection B. Providing postmortem care for a client who has just died C. Suctioning a tracheostomy for a client who has a recent head injury D. Changing a peripheral IV dressing for a client who is postoperative

Correct Answer is B

Explanation

A) Administering vaginal cream to a client who has a vaginal infection - This task involves administration of medication, which typically falls within the scope of licensed nursing practice.

B) Providing postmortem care for a client who has just died - When delegating tasks to assistive personnel, nurses can assign activities such as providing postmortem care.
C) Suctioning a tracheostomy for a client who has a recent head injury - Suctioning a tracheostomy requires specialized training and is typically performed by licensed nursing staff.
D) Changing a peripheral IV dressing for a client who is postoperative - Changing an IV dressing is a task that require skills of a licensed nurse hence cannot be delegated to an assistive personnel.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is B

Explanation

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Correct Answer is B

Explanation

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