An adolescent client who recently lost most sight in both eyes has been admitted for evaluation. The nurse observes an unlicensed assistive personnel (UAP) who is assisting the client to walk in the hallway for the first time since admission, as seen in the picture. Which action should the nurse take?

Encourage the UAP to continue to assist the client down the hallway.

Demonstrate to the UAP how to assist the client with ambulation more safely.

Instruct the UAP to guide the client back to his room right away.

Advise the UAP to stay nearby but allow the client to ambulate independently.

Answer and Explanation

The Correct Answer is B

A.   While it is important to support the UAP's efforts, simply encouraging them to continue without
assessing the method used may not ensure the safety of the client. The UAP’s approach to assisting the
client could potentially involve unsafe practices, especially given the client's significant vision loss.
B.   Demonstrating safe ambulation techniques to the UAP ensures that the client is guided effectively and safely. For clients with significant vision loss, it is essential to use specific techniques, such as providing clear verbal cues, using a sighted guide method (e.g., having the client hold the guide's arm), and ensuring a clear and safe path.
C.   This choice may be premature without evaluating the current situation. It assumes the UAP is providing unsafe assistance, but it does not provide a solution to how the UAP should assist the client in a more effective manner.
D.   Allowing the client to ambulate independently, especially after significant vision loss, might not be safe. Clients who have recently lost their vision may require assistance to navigate their environment safely. While staying nearby can offer some level of safety, it is not sufficient if the client needs hands- on guidance and support to avoid hazards.

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Correct Answer is B

Explanation

A. Document in the EHR: While documenting the event in the electronic health record is important, it's not sufficient to address the medication error. An incident report provides a more comprehensive and structured approach to documenting and investigating the event.
B. When a medication error occurs, it's crucial to document the event through an incident report. This helps to identify the root cause of the error, prevent similar occurrences in the future, and ensure patient safety. An incident report should include a detailed description of the event, the actions taken, and any potential contributing factors.
C. While informing the next shift is important for continuity of care, it's not the most immediate action needed to address the medication error. Completing an incident report is a higher priority.
D. Notifying the healthcare provider is important, but it should be done in conjunction with completing an incident report. The incident report provides a detailed record of the event, which can be shared with the healthcare provider for further review and investigation.

A. Wear an emergency response pendant at home. B. Recommend installing grab bars by toilets, bathtub, and shower. C. Request that a family member move in with her. D. Encourage exercise to improve balance and mobility. E. Have the home health nurse assess the home for fall risks.

Correct Answer is ["A","B","D","E"]

Explanation

A. This device can be used to summon help quickly in case of a fall or other emergency.
B. Grab bars provide extra support and can help prevent falls in areas where the risk is high.
C. Request that a family member move in with her might be a solution for some people but it is not always practical or desirable. It's important to consider the client's preferences and independence when making recommendations.
D. Regular exercise can help strengthen muscles and improve balance, reducing the risk of falls.
E. A home health nurse can identify potential hazards in the home and make recommendations for modifications to improve safety.

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Naxlex Comprehensive Predictor Exams

After an IV antibiotic is started, the nurse determines that the medication is not prescribed for the client and stops the infusion. Which action should the nurse implement next?

Correct Answer is B

Explanation

An older adult woman who lives alone talks with the clinic nurse about her fears of falling at home. Which interventions should the nurse suggest? Select all that apply.

Correct Answer is ["A","B","D","E"]

Explanation

An older adult client grimaces and demonstrates guarding behavior, but denies experiencing pain when asked by the nurse to rate the pain on a numeric scale. Which action should the nurse take next?

Which assessment data reflects the need for the nurse to include the problem, "Risk for falls" in a client's plan of care? Reference Range: Hemoglobin [14 to 18 g/dL (140 to 180 g/L)]

The electronic medication system alerts the nurse that the medication dose scanned for the client is two times higher than the dose prescribed. Which action should the nurse implement?

When assessing a client's pain, the nurse determines the location and intensity of the pain. To gather data about the quality of the pain, which action should the nurse take?

The nurse identifies the hospitalized client in which situation as being at highest risk for the development of a healthcare associated infection (HAI)?

Which breakfast selection indicates that the client understands the nurse's instructions about the dietary management of osteoporosis?