A nurse is observing an assistive personnel (AP) changing the linens on the bed of a client who is immobile. Which of the following actions by the AP should the nurse identify as an indication of the need to intervene?

Rolls the client to one side of the bed

Reaches over the bed to straighten the fitted sheet

Lowers the side rail on the side of the bed closest to the AP

Raises the bed to waist level

Answer and Explanation

The Correct Answer is B

A. Rolling the client to one side of the bed is an appropriate action to change the linens.
B. Reaching over the bed to straighten the fitted sheet can cause strain and potential injury to the AP's back and should be corrected.
C. Lowering the side rail on the side of the bed closest to the AP is necessary for changing the linens safely.
D. Raising the bed to waist level is an appropriate action to ensure proper body mechanics and prevent injury.

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Correct Answer is ["A","C","E","F"]

Explanation

A. The client has not received pneumococcal vaccine, which increases susceptibility to pneumococcal pneumonia.
B. The client is oriented to time place and person which is normal.
C. The client has not received influenza vaccine, which increases susceptibility to pneumococcal pneumonia.
D. The client has no significant health history other than the primary concern.
E. The client's fluid intake seems to be reduced, as indicated by their decreased urination and reports of not drinking much water due to a sore throat, which can contribute to the risk of infection.
F. Being 70 years old increases susceptibility to respiratory infections like pneumonia.
G. No history of smoking reduces risk compared to smokers, but is still a risk factor in pneumonia development.

A. Elevated ST segment B. Abnormally prominent U wave C. Wide QRS D. Inverted P wave

Correct Answer is B

Explanation

Rationale:
A. Elevated ST segment is typically associated with myocardial infarction or pericarditis, not hypokalemia.
B. An abnormally prominent U wave is a classic sign of hypokalemia on an EKG.
C. Wide QRS complex can be seen with severe hyperkalemia or other conditions affecting ventricular conduction.
D. Inverted P wave is not associated with hypokalemia; it is more often related to atrial conduction abnormalities or ectopic atrial rhythm.

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A nurse is observing an assistive personnel (AP) changing the linens on the bed of a client who is immobile. Which of the following actions by the AP should the nurse identify as an indication of the need to intervene?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse in an emergency department (ED) is admitting a client. Exhibits Select 4 findings in the client's medical record that place them at risk for pneumonia.

Correct Answer is ["A","C","E","F"]

Explanation

A nurse is reviewing the EKG strip of a client who has prolonged vomiting. Which of the following abnormalities on the client's EKG should the nurse interpret as a sign of hypokalemia?

Correct Answer is B

Explanation

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