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. "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.

A. Verify the bilirubin level of the tube contents. B. Auscultate for air insufflation. C. Request a chest x-ray. D. Check the pH level of gastric contents.

Correct Answer is C

Explanation

A. Verifying the bilirubin level of the tube contents is not a reliable method for confirming tube placement and may not provide accurate information.
B. Auscultating for air insufflation can help detect tube placement in the respiratory tract but may not reliably confirm placement in the gastrointestinal tract.
C. Requesting a chest x-ray is the most reliable method for confirming the placement of a feeding tube, as it allows visualization of the tube's position relative to anatomical landmarks.
D. Checking the pH level of gastric contents can help differentiate between gastric and respiratory placement but may not provide definitive confirmation of tube placement.

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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 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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Correct Answer is C

Explanation

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