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.

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Correct Answer is B

Explanation

Choice A reason

While thinning of secretions can be a positive sign, it's not always visible. A decrease in peak inspiratory pressure is a more objective indicator of improved airway patency.

Choice B reason.

Peak inspiratory pressure is the maximum pressure required to push air into the lungs. If suctioning is effective, it will remove secretions and reduce airway resistance, leading to a decrease in peak inspiratory pressure

Choice C reason:

While a productive cough can indicate that secretions are being moved, it doesn't directly measure the effectiveness of suctioning.

Choice D reason:

Flattening of the artificial airway cuff: Flattening of the artificial airway cuff is not a relevant indicator of the effectiveness of suctioning. The cuff of an endotracheal tube is inflated to prevent air leaks around the tube and to maintain proper ventilation. It is not directly related to the effectiveness of suctioning.

A. I will disinfect contaminated hard surfaces with a mixture of one part peroxide to 10 parts water. B. I will place used sharp items in an empty cereal box for disposal. C. I will put soiled dressings in a tied plastic bag before placing them in the trash. D. I will use animal-skin condoms when having sex.

Correct Answer is C

Explanation

The correct answer is C. Putting soiled dressings in a tied plastic bag before placing them in the trash reduces the risk of exposure to blood-borne pathogens for anyone who handles the trash.

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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 suctioning the airway of a client who is receiving mechanical ventilation via an endotracheal tube. Which of the following findings should the nurse identify as an indication that the suctioning has been effective?

Correct Answer is B

Explanation

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Correct Answer is C

Explanation

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