Patient Data

Exhibits

Each row and each column must have at least one, but may have more than one, response option selected.
Intervention: Promotes safety/ Does not promote safety

Place all client belongings out of reach

Instruct the client to call before getting up

Initiate use of the bed alarm

Complete a swallow study before giving anything by mouth

Place the client in a room near the elevator

Provide a call button kept within reach

Answer and Explanation

The Correct Answer is {"A":{"answers":"B"},"B":{"answers":"A"},"C":{"answers":"A"},"D":{"answers":"A"},"E":{"answers":"B"},"F":{"answers":"A"}}

A.   placing all client belongings out of reach (A) does not promote safety as it may lead the client to attempt to get up unassisted to retrieve their items, increasing the risk of falls.
B.   Instructing the client to call before getting up ensures that assistance is provided, preventing falls due to potential weakness or balance issues.
C.   Initiating the use of a bed alarm helps in monitoring the client's movements, which is crucial in preventing falls, especially when the client might have impaired mobility.
D.   Completing a swallow study before giving anything by mouth is essential to assess the risk of aspiration, which can be heightened due to possible swallowing difficulties post- stroke.
E.   Placing the client in a room near the elevator does not directly promote safety; it could be beneficial for logistical reasons but does not address the client's immediate safety needs.
F.   Providing a call button within reach allows the client to alert staff promptly if they need assistance, thus reducing the risk of injury.

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Free Nursing Study Resources

Correct Answer is B

Explanation

A. Monitoring incision drainage is important for infection and wound healing but not directly related to the effectiveness of compression devices.
B. Observing both lower extremities for redness and swelling directly assesses the effectiveness of the pneumatic compression devices in preventing deep vein thrombosis (DVT).
C. Evaluating the use of an incentive spirometer is important for respiratory function but unrelated to the compression devices.
D. Palpating peripheral pulse points is useful for circulation assessment but does not specifically evaluate the prevention of DVT, which is the primary purpose of the compression devices.

A. Encourage sitting up and ambulation B. Monitor for bleeding once daily C. Use Incentive spirometer every 1 hour D. Promote adequate hydration E. Assess for sedation after pain medications F. Complete neurologic assessment every 2 hours G. Administer pain medication after activity

Correct Answer is ["A","C","D","E","G"]

Explanation

A. Early ambulation helps prevent complications such as atelectasis, pneumonia, and deep vein thrombosis (DVT). It also promotes intestinal motility.
B. Monitoring for bleeding should be more frequent, especially in the immediate postoperative period, rather than just once daily.
C. This helps prevent respiratory complications such as atelectasis and promotes lung expansion.
D. Adequate hydration is essential to maintain fluid balance, promote healing, and prevent complications such as urinary tract infections and constipation.
E. Monitoring for sedation is crucial to ensure that pain medications are not causing excessive drowsiness, which could impair the client's ability to participate in activities such as ambulation and use of the incentive spirometer.

F. While assessing neurological status is important, frequent neurological assessments are more relevant for clients with neurological conditions or concerns. In this case, routine assessments should be sufficient unless the client has specific neurological symptoms.
G. Pain medications should be administered prophylactically before activity. However, it can also be administered after activity in case the client complains of pain.

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Patient Data Exhibits Each row and each column must have at least one, but may have more than one, response option selected. Intervention: Promotes safety/ Does not promote safety

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

In evaluating the effectiveness of a postoperative client's intermittent pneumatic compression devices, which assessment is most important for the nurse to complete?

Correct Answer is B

Explanation

Patient Data Exhibits Click to select the 5 most important nursing interventions for postoperative client care.

Correct Answer is ["A","C","D","E","G"]

Explanation

The nurse is preparing a client for discharge who underwent a percutaneous nephrolithotomy with nephrostomy tube placement. Which instruction should the nurse include in the client's postoperative discharge teaching?

106 A client with a fracture of the right femur has had skeletal traction applied. Which intervention should the nurse include in the client's nursing care plan?

A client who is participating in an anger management assignment asks to make a leather belt in occupational therapy. The client begins pounding the leather vigorously with a mallet to imprint designs on the belt. Which defense mechanism is the client using?

The nurse is preparing to obtain a rapid coronavirus (COVID-19) test for a client who was exposed to the virus eight days ago. The client is experiencing fever, cough, and shortness of breath. Which action is most important for the nurse to take?

When assessing a client with an ionized calcium level of 17 mg/dL (4.25 mmol/L), which intervention is most important for the nurse to implement? Reference Range lonized Calcium [Adult 4.6 to 5.1 mg/dL (1.15 to 1.35 mmol/L)]

A client receives a prescription for acetaminophen 1,000 mg PO every 8 hours PRN for pain. The bottle is labeled "Acetaminophen for Oral Suspension, USP 500 mg per 15 mL." How many tablespoons should the nurse instruct the client to take with each dose? (Enter numerical value only.)

Patient Data

Exhibits

Each row and each column must have at least one, but may have more than one, response option selected.
Intervention: Promotes safety/ Does not promote safety