A nurse is teaching a class at a local senior center regarding safety in the home. A client states, "I am afraid of falling because I live alone and have no one to help me." Which of the following statements should the nurse make?

"You can obtain a personal response system that will be activated if you fall."

"You should contact a family member once a week to keep in touch."

"You can have an unlicensed assistive personnel (UAP) come to your house daily to stay with you."

"You need to move to a skilled nursing facility where they can prevent falls."

Answer and Explanation

The Correct Answer is A

Rationale:
A. "You can obtain a personal response system that will be activated if you fall.": A personal emergency response system allows the client to summon help immediately after a fall, promoting independence and safety for individuals living alone.

B. "You should contact a family member once a week to keep in touch.": Weekly contact provides emotional support but does not ensure timely assistance in the event of a fall. Regular communication is helpful, yet it does not directly reduce fall risk or guarantee safety if an emergency occurs.

C. "You can have an unlicensed assistive personnel (UAP) come to your house daily to stay with you.": Having a UAP visit daily may not be realistic or necessary, especially for independent seniors. This does not provide continuous supervision or an immediate response in case of a fall occurring outside scheduled visits.

D. "You need to move to a skilled nursing facility where they can prevent falls.": Suggesting relocation is premature and disregards the client’s desire for independence. Fall prevention strategies and assistive technology should be explored before recommending institutional care.

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Correct Answer is D

Explanation

Rationale:
A. Limit teaching sessions about the procedure to 20 min: While preschoolers have limited attention spans, the focus should be on using age-appropriate language and explanations rather than strictly timing the teaching session. The quality and clarity of instruction are more important.

B. Ask the parents to wait outside the room during the procedure: Preschoolers often feel safer and more cooperative when a parent is present. Removing parents can increase anxiety and resistance, so parental presence is encouraged.

C. Instruct the child in deep-breathing methods prior to the procedure: Deep-breathing exercises can help with relaxation, but preschoolers may have difficulty understanding or performing them effectively. Simple explanations and reassurance are more appropriate.

D. Explain in simple terms how the procedure will affect the child: Providing a clear, age-appropriate explanation helps the preschooler understand what to expect, reduces fear, and promotes cooperation. Using simple terms tailored to the child’s developmental level is the most effective preparation.

A. Change the drainage tubing every 48 hr. B. Irrigate the drain to maintain suction. C. Observe for drainage flow through the tubing. D. Remove the drain if output from the drain increases.

Correct Answer is C

Explanation

Rationale:
A. Change the drainage tubing every 48 hr: Routine changing of drainage tubing is not recommended unless it becomes contaminated or occluded. Frequent manipulation increases the risk of infection and compromises the sterile system.

B. Irrigate the drain to maintain suction: Irrigating a closed wound drainage system can introduce pathogens and disrupt the vacuum, increasing the risk of infection. Closed systems are designed to maintain suction without routine irrigation.

C. Observe for drainage flow through the tubing: Monitoring the amount, color, and consistency of drainage is essential to assess wound healing and detect complications such as infection or hemorrhage. Observing flow ensures the system is functioning properly and provides critical data for clinical decisions.

D. Remove the drain if output from the drain increases: Increased output can indicate ongoing bleeding or infection and should be reported to the provider. Premature removal of the drain in this situation could lead to fluid accumulation, wound dehiscence, or infection.

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A nurse is teaching a class at a local senior center regarding safety in the home. A client states, "I am afraid of falling because I live alone and have no one to help me." Which of the following statements should the nurse make?

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Naxlex Comprehensive Predictor Exams

A nurse is preparing to perform a dressing change on a preschooler. Which of the following actions should the nurse take to prepare the child for the procedure?

Correct Answer is D

Explanation

A nurse is caring for a client who has a closed wound drainage system. Which of the following interventions should the nurse include in the plan care?

Correct Answer is C

Explanation

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