A nurse is supervising an assistive personnel (AP) who is caring for a client who is at risk for falls. For which of the following actions by the AP should the nurse intervene?

Assists the client to the bathroom every 2 hr

Raises all four side-rails on the client's bed

Locks the wheels on the client's bed

Clears furniture from the path leading to the bathroom

Answer and Explanation

The Correct Answer is B

The correct answer is B. Raising all four side-rails on the client's bed is considered a restraint and can increase the risk of injury if the client tries to climb over them. The nurse should intervene and instruct the AP to lower one or two side-rails and use other fall prevention measures, such as bed alarms, nonskid footwear, and frequent checks.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is A

Explanation

Choice A reason:

Urine specific gravity is the measurement of the concentration of solutes in urine and is an important indicator of the client's hydration status and kidney function. A specific gravity of 1.035 is relatively high, suggesting concentrated urine. High urine specific gravity can be a sign of dehydration or other kidney-related issues.

Reporting this finding to the provider is crucial because it could indicate potential problems with the client's fluid balance and kidney function. The provider may need to assess further, conduct additional tests, or initiate appropriate interventions to address the client's hydration and renal status.

Choice B reason:

Prealbumin: A prealbumin level of 25 mg/dL is within the normal range (usually 15-35 mg/dL) and may not require immediate reporting to the provider. Prealbumin is used to assess nutritional status, and this result suggests that the client's nutritional status is within the normal range.

Choice C reason:

Temperature: The provided information does not include any data about the client's temperature, and there are no signs of infection mentioned. Unless there are specific signs or symptoms of fever or infection, reporting the temperature is not necessary based on the given data.

Choice D reason

Bowel sounds: The provided information does not include any data about the client's bowel sounds, and there are no indications of gastrointestinal issues or abnormalities. Bowel sounds may not be relevant to report unless there are specific symptoms or signs of GI disturbances.

Correct Answer is {"dropdown-group-1":"D"}

Explanation

The nurse should prepare to administer naloxone and oxygen 10 L/min via face mask. Naloxone is a medicine that can reverse the effects of opioid drugs like fentanyl, which may have caused respiratory depression in the client.

Oxygen can help improve the client's oxygen saturation, which has dropped below 90%.

The nurse should avoid giving acetaminophen, which is not indicated for this situation, or additional doses of propofol or fentanyl, which may worsen the client's condition.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

A nurse is supervising an assistive personnel (AP) who is caring for a client who is at risk for falls. For which of the following actions by the AP should the nurse intervene?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is reviewing the medical record of a client. Which of the following findings should the nurse report to the provider? These are the medical report: Urine specific gravity 1.035, albumin 4.5 mg/L, prealbumin 25 mg/dL and potassium 4.2 mg/dL

Correct Answer is A

Explanation

A nurse is assisting with the care of a client in an outpatient clinic. Exhibits Complete the following sentence by using the lists of options. The nurse should prepare to administer naloxone and

Correct Answer is {"dropdown-group-1":"D"}

Explanation

A nurse is collecting data from a client. The nurse should identify that which of the following manifestations is an indication of a candida infection?

A nurse is monitoring a client who has received external radiation for throat cancer. Which of the following findings should the nurse expect?

A nurse is teaching a prenatal class about infection prevention at a community centre. Which of the following statements by a client indicates an understanding of the teaching?

A nurse is providing teaching about digoxin administration to the parents of a toddler who has heart failure. Which of the following statements should the nurse include in the teaching?

A nurse is caring for a client who has schizophrenia and is taking an antipsychotic medication. Which of the following screening tools should the nurse use to identify tardive dyskinesia?

A nurse is assisting with a prenatal examination of a client who is at 8 weeks of gestation.The nurse notes that the client's vagina and vulva are a purplish color. The nurse should document this finding as which of the following?

A nurse is reinforcing discharge teaching with a client who has a prescription for antibiotictherapy. The client reports experiencing diarrhea when taking antibiotics. Which of the following foods should the nurse recommend to lessen the occurrence of diarrhea?