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.

Wear an emergency response pendant at home.

Recommend installing grab bars by toilets, bathtub, and shower.

Request that a family member move in with her.

Encourage exercise to improve balance and mobility.

Have the home health nurse assess the home for fall risks.

Answer and Explanation

Correct Answer : A,B,D,E

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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Correct Answer is A

Explanation

A. Positioning the package of gauze pads on a sterile field is an appropriate action to maintain sterility and ensure that all items used in the procedure remain uncontaminated. However, this step should be considered only if the solution was poured correctly and the sterility of the gauze pads and solution has been maintained.
B. Discarding the open bottle of solution is not necessary unless it has been contaminated. If the solution is still sterile and has not been contaminated (e.g., by touching non-sterile surfaces), there is no need to discard it. The focus should be on ensuring that the solution and all other items remain sterile.
C. Recapping the solution is not recommended because it can lead to contamination. Instead, the solution should be left open or covered with a sterile cap, if provided. Applying sterile gloves is essential for maintaining sterility during the dressing change procedure, but this should be done after ensuring that all supplies and steps are in order.
D. This action would be necessary only if there was a contamination issue or if the sterility of the supplies or solution was compromised. If the sterile technique was not followed properly or there was a risk of contamination, starting the procedure again with new supplies would be appropriate.

A. Use background music to promote relaxation. B. Turn on overhead lights while reviewing instructions. C. Stand behind the client to avoid intimidation. D. Provide handouts written at a 12th grade reading level.

Correct Answer is D

Explanation

A. While music can be relaxing, it may also be distracting and make it difficult for the client to focus on the instructions.
B. Bright overhead lights can be uncomfortable and may even cause strain on the eyes. It's generally better to use soft, natural lighting when reviewing instructions.
C. Standing behind the client can make them feel intimidated or uncomfortable, especially if they are already feeling anxious or overwhelmed. It's better to stand in front of the client and maintain eye contact to show that you are engaged and attentive.
D. Older adults may have difficulty understanding written information that is too complex. Providing handouts written at a 12th grade reading level ensures that the client can easily comprehend the instructions and follow them at home.

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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.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

When preparing to change a client's sterile dressing, the nurse pours sterile solution over a package of gauze pads as seen in the picture. Which should the nurse do next?

Correct Answer is A

Explanation

An older client with colorectal carcinoma receives a colostomy following a bowel resection and the nurse is reviewing written instructions about colostomy care that the client will take home after discharge. Which action should the nurse include when reviewing the instructions with the client?

Correct Answer is D

Explanation

The charge nurse is observing a new nurse administering care during new hire orientation at the hospital. Which activity by the new nurse indicates correct body movement and posture to reduce the risk for injury?

The nurse is teaching another nurse about the administration of medication using the Z track technique. Which is the primary reason for using a Z track technique to administer a medication?

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?

A client is ambulating with a two wheeled walker by rolling the walker forward and then moving each foot forward. The nurse notes that the client's elbows are slightly flexed when grasping the hand bar. After the client returns to the chair, which action should the nurse implement?

On the first postoperative day, the nurse finds an older adult client disoriented and trying to climb over the bed railing. The client was oriented to person, place, and time on admission. Which intervention should the nurse implement first?

When evaluating the effectiveness of a client's nursing care, the nurse first reviews the expected outcomes identified in the plan of care. What action should the nurse take next?

The nurse observes a colleague putting printed copies of client information in a uniform pocket before going home. Which action should the nurse take?

The unlicensed assistive personnel (UAP) tells the nurse that an older client has requested powder applied after a tub bath to relieve itchy dry skin. Which instruction should the nurse provide to the UAP?