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) Recheck the client's SaO2 level after having the client cough and clear their throat.
- This action helps determine if the low SaO2 level is due to a transient cause such as mucus or secretions blocking the airway.
B) Notify the charge nurse of the client's condition. - While important, this action should come after assessing and addressing the client's immediate needs.
C) Review the client's most recent SaO2 level in the medical record. - This information may provide context but does not address the current low SaO2 level.
D) Check the client's medical records to see which medications were recently admitted. - Medications may contribute to respiratory issues, but addressing the client's immediate respiratory distress takes priority.
Correct Answer is B
Explanation
A) To calculate the intake volume for the I&O chart, the nurse should convert all liquid measurements to milliliters. One ounce is approximately 30 milliliters. Therefore, 8 oz of milk is 240 mL, 10 oz of water is 300 mL, and 4 oz of gelatin (since it's considered a liquid for I&O purposes) is 120 mL. The egg, bacon, and biscuits are not included in the liquid intake calculation. Adding up the liquids, the total intake is 240 mL + 300 mL + 120 mL, which equals 660 mL.
B) To calculate the intake volume for the I&O chart, the nurse should convert all liquid measurements to milliliters. One ounce is approximately 30 milliliters. Therefore, 8 oz of milk is 240 mL, 10 oz of water is 300 mL, and 4 oz of gelatin (since it's considered a liquid for I&O purposes) is 120 mL. The egg, bacon, and biscuits are not included in the liquid intake calculation. Adding up the liquids, the total intake is 240 mL + 300 mL + 120 mL, which equals 660 mL.
C) To calculate the intake volume for the I&O chart, the nurse should convert all liquid measurements to milliliters. One ounce is approximately 30 milliliters. Therefore, 8 oz of milk is 240 mL, 10 oz of water is 300 mL, and 4 oz of gelatin (since it's considered a liquid for I&O purposes) is 120 mL. The egg, bacon, and biscuits are not included in the liquid intake calculation. Adding up the liquids, the total intake is 240 mL + 300 mL + 120 mL, which equals 660 mL.
D) To calculate the intake volume for the I&O chart, the nurse should convert all liquid measurements to milliliters. One ounce is approximately 30 milliliters. Therefore, 8 oz of milk is 240 mL, 10 oz of water is 300 mL, and 4 oz of gelatin (since it's considered a liquid for I&O purposes) is 120 mL. The egg, bacon, and biscuits are not included in the liquid intake calculation. Adding up the liquids, the total intake is 240 mL + 300 mL + 120 mL, which equals 660 mL.
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