A nurse is reinforcing teaching with an older adult client about home safety. Which of the following client statements indicates an understanding of the teaching?
"I will place a night light in the hallway near the bathroom."
"I will use a standard height toilet seat."
"I will set my water heater to 145 degrees Fahrenheit."
"I will cover extension cords with throw rugs.”
The Correct Answer is A
Rationale:
A. "I will place a night light in the hallway near the bathroom.": Installing night lights in commonly used paths, such as the hallway to the bathroom, helps prevent falls by improving visibility during nighttime trips, which is especially important for older adults with limited vision or balance.
B. "I will use a standard height toilet seat.": Standard height toilet seats can make sitting and standing more difficult for older adults. Raised toilet seats are safer and reduce the risk of falls by minimizing the effort required to use the toilet.
C. "I will set my water heater to 145 degrees Fahrenheit.": This temperature is too high and increases the risk of scald injuries. Water heaters should be set to no more than 120°F to protect older adults from accidental burns, as their skin is often thinner and more sensitive.
D. "I will cover extension cords with throw rugs.": Covering cords with rugs creates a tripping hazard. Extension cords should be secured against walls or removed altogether to reduce fall risk, especially in homes with elderly residents.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Rationale:
A. Instruct the client to lie supine with his knees flexed: Flexing the knees reduces tension on the abdominal wall and helps prevent further protrusion of abdominal contents. This position is critical for stabilizing the evisceration while awaiting surgical intervention.
B. Cover the wound with a dry sterile dressing: Using a dry dressing can cause the exposed organs to dry out and adhere to the material, increasing the risk of tissue damage. A moist sterile dressing is needed to protect and preserve the protruding tissues.
C. Position the client in semi-Fowler's position: Elevating the head of the bed increases intra-abdominal pressure and can worsen evisceration. This position should be avoided to prevent strain on the open surgical site.
D. Cover the wound with a transparent dressing: Transparent dressings are not suitable for eviscerations because they do not provide adequate moisture or protection for exposed organs. A sterile saline-moistened dressing is required to maintain tissue integrity.
Correct Answer is ["31"]
Explanation
Calculation:
Total volume to be infused = 500 mL.
- Convert the infusion time from hours to minutes.
Infusion time = 4 hr × 60 min/hr
= 240 min.
Drop factor = 15 gtt/mL.
- Calculate the flow rate in drops per minute (gtt/min).
Flow rate (gtt/min) = (Total volume (mL) × Drop factor (gtt/mL)) / Infusion time (min)
= (500 mL × 15 gtt/mL) / 240 min
= 7500 gtt / 240 min
= 31.25 gtt/min.
Rounded to the nearest whole number:
= 31 gtt/min.
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