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 A
Explanation
A) Placing the restraint across the client's chest - This is not a safe practice since it can restrict breathing increasing the risk of asphyxiation.
B) Applying the restraint over the client's gown - Restraints should be applied over the clients gown and not directly to the client's skin to prevent friction and skin breakdown.
C) Using a quick-release tie to secure the restraint - Quick-release ties are important for ensuring that restraints can be quickly removed in case of an emergency.
D) Tying the restraint to the bed frame – Tying restraints on the bed frame is the recommended practice. Restraints should not be tied on the bed rails to avoid injuries if the side rails are released.
Correct Answer is D
Explanation
A. Urinate after the specimen collection- Urinating after collecting the stool specimen does not affect the collection process.
B. Place 1.3 cm (0.5 in) of formed stool into a culture tube- The amount of stool needed for collection depends on the specific instructions provided, but typically, a small amount is sufficient.
C. Keep the specimen in a warm area- Stool specimens are usually kept at room temperature or refrigerated, depending on the specific requirements of the test.
D. Avoid placing toilet tissue in the bedpan after defecation- Placing toilet tissue in the bedpan can contaminate the stool specimen and affect the test results. Instructing the client to avoid doing so helps ensure the integrity of the sample.
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