A nurse is providing reinforcing discharge instructions to a client who has a prescription for oxygen use at home.
Which of the following information should the nurse include? (Select all that apply.)

Family members who smoke must be at least 10 ft from the client when oxygen is in use.

Nail polish remover or hair spray should not be used near a client who is receiving oxygen.

A "No Smoking" sign should be placed on the front door.

Cotton bedding and clothing should be replaced with items made from wool.

A fire extinguisher should be readily available in the home.

Answer and Explanation

Correct Answer : D

Choice A rationale:

Tying the straps of the restraints in a double knot is incorrect. This action can make it difficult to quickly release the restraints in case of an emergency. A single, quick-release knot is recommended to ensure the client's safety.

Choice B rationale:

Tying the restraints to the side rails is incorrect. Attaching restraints to the side rails can cause injury to the client and is not a proper restraint application method. Restraints should be tied to the bed frame, not the side rails, to prevent harm.

Choice C rationale:

Placing the padding of the restraints against the client's bony prominences is incorrect. While padding is important to prevent skin breakdown and pressure ulcers, the correct placement of the padding alone does not indicate a comprehensive understanding of proper restraint application.

Choice D rationale:

Inserting one finger between the client's wrist and the restraint is the correct action. This technique ensures that the restraints are not too tight, allowing for proper circulation and preventing injury to the client. The ability to insert one finger indicates that the restraints are snug but not constrictive, maintaining the client's safety and comfort.

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Correct Answer is D

Explanation

Choice A rationale:

Ears are located on the sides of the head, not between the cranial and thoracic cavities. The ears are lateral structures on the head.

Choice B rationale:

Elbow is a joint located in the upper limb, specifically in the arm. It is not between the cranial and thoracic cavities. The elbow is a joint that allows the forearm to bend.

Choice C rationale:

Knee is a joint in the lower limb, connecting the thigh bone to the shin bone. It is not located between the cranial and thoracic cavities. The knee joint allows for movements like bending and straightening of the leg.

Choice D rationale:

The nape of the neck refers to the back of the neck. It is the posterior part of the neck, located between the cranial (head) and thoracic (upper chest) cavities. The nape of the neck is a specific anatomical location.

A. Instruct the clients to use the call light. B. Keep the clients' rooms dark. C. Move overbed tables away from the bed. D. Perform client checks every 4 hours.

Correct Answer is A

Explanation

The correct answer is A. Instruct the clients to use the call light.

Choice A rationale:

Instructing clients to use the call light ensures they can request assistance before getting up, which is a key strategy in preventing falls, especially during the night when visibility is reduced and the risk of disorientation is higher.

Choice B rationale:

Keeping the clients' rooms dark can increase the risk of falls as it makes it difficult for clients to see obstacles and navigate their environment safely. Adequate lighting is important for fall prevention.

Choice C rationale:

Moving overbed tables away from the bed can actually make it harder for clients to reach essential items and might increase the risk of falls if clients have to stretch or lean awkwardly to get what they need. The overbed table should be positioned within easy reach.

Choice D rationale:

Performing client checks every 4 hours is not frequent enough to effectively monitor at-risk clients. More frequent checks, such as hourly, are recommended to ensure safety and promptly address any needs that could prevent a fall.

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A nurse is providing reinforcing discharge instructions to a client who has a prescription for oxygen use at home.Which of the following information should the nurse include? (Select all that apply.)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Which body part is in the following location? Posterior and between the cranial and thoracic cavities.

Correct Answer is D

Explanation

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Correct Answer is A

Explanation

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A nurse is providing reinforcing discharge instructions to a client who has a prescription for oxygen use at home.
Which of the following information should the nurse include? (Select all that apply.)