A nurse is reviewing a client's electronic medical record (EMR). Which of the findings should the nurse identify as a risk factor for a potential accident or injury?

History of dementia

Steady gait

History of gastric reflux

Age of 45

Answer and Explanation

The Correct Answer is A

A.   History of dementia- Dementia can impair cognitive function and increase the risk of accidents or injuries, such as falls or wandering.
B.   Steady gait- A steady gait indicates good balance and is not typically considered a risk factor for accidents or injuries.
C.   History of gastric reflux- Gastric reflux may cause discomfort but is not directly related to an increased risk of accidents or injuries.
D.   Age of 45- While age can be a risk factor for certain conditions, such as falls in older adults, being 45 years old alone does not necessarily indicate an increased risk of accidents or injuries.

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Correct Answer is B

Explanation

A) Apply cornstarch powder to the perineal area. - Cornstarch powder may increase the risk of infection and should be avoided in the perineal area, especially for clients with fecal incontinence.
B) Place a moisture barrier ointment over the perineal area. - Moisture barrier ointment helps protect the skin from irritation and breakdown caused by fecal incontinence.
C) Turn the client every 4 hr. - Turning the client every 2 hours is recommended for preventing pressure ulcers, but it does not specifically address fecal incontinence.
D) Cleanse the perineal area with povidone-iodine solution. - Povidone-iodine solution is not typically used for routine perineal care and may irritate the skin.

A. "He is here in the hospital, but I cannot tell you anything else." B. "I cannot confirm or deny that we have a client by that name." C. "The client's condition is stable right now." D. "I will tell him you called."

Correct Answer is B

Explanation

A. "He is here in the hospital, but I cannot tell you anything else."- This response respects the client's confidentiality and does not disclose protected health information to unauthorized individuals.

B. "I cannot confirm or deny that we have a client by that name."- This response is evasive and does not provide any useful information.
C. "The client's condition is stable right now."- Disclosing the client's condition without their consent is a violation of confidentiality.
D. "I will tell him you called."- This response breaches the client's confidentiality by confirming their presence in the hospital.

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A nurse is reviewing a client's electronic medical record (EMR). Which of the findings should the nurse identify as a risk factor for a potential accident or injury?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for an older adult client who has fecal incontinence. Which of the following actions should the nurse take?

Correct Answer is B

Explanation

A nurse on a medical-surgical unit receives a telephone call from an individual who identifies himself as the client's employer. The employer asks the nurse about the client's condition. Which of the following is an appropriate response by the nurse?

Correct Answer is B

Explanation

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