The nurse is planning a fall prevention program for the residents at a long-term care facility. Which intervention is most important in providing a safe environment?

Apply a vest restraint prophylactically to confused residents.

Accompany residents older than 80 years during ambulation.

Encourage clients to wear rubber-soled shoes.

Leave the hall lights on during the night.

Answer and Explanation

The Correct Answer is C

Choice A: Applying restraints should not be the first approach in fall prevention and is associated with risks and ethical considerations.

Choice B: Accompanying residents during ambulation is a helpful practice but may not be feasible at all times. It's essential to promote independence when possible.

Choice C: Encouraging clients to wear rubber-soled shoes is an important fall prevention measure, as it can provide better traction and stability when walking.

Choice D: Leaving the hall lights on during the night may be helpful, but it is not the most critical intervention for fall prevention. Proper footwear and other measures should take precedence.

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Correct Answer is A

Explanation

Choice A: Uremic frost is a symptom of advanced kidney disease and can result in deposits of urea crystals on the skin. This can cause itching and discomfort, making it difficult for the client to maintain good hygiene and self-care. Therefore, addressing hygiene self-care deficit related to uremic frost is a priority in the plan of care for a client with renal osteodystrophy.

Choice B: This is not directly related to renal osteodystrophy and is more related to the presence of a catheter.

Choice C: This is not typically associated with renal osteodystrophy unless there are specific mobility issues related to bone problems.

Choice D: This may be relevant for clients with CKD, but it is not specific to renal osteodystrophy, which primarily involves bone mineral imbalances.

A. Nasogastric tube insertion. B. Iced saline lavage. C. Administration pantoprazole (Protonix) IV, a proton pump inhibitor. D. Emergency abdominal surgery.

Correct Answer is D

Explanation

Choice A: Nasogastric tube insertion may be indicated in the management of a client with peptic ulcer disease (PUD) to assess bleeding, relieve gastric distention, or administer medications. However, in this scenario, the client's presentation with sudden severe upper abdominal pain, a tender and rigid abdomen, hypotension, and tachycardia suggests a potentially life-threatening condition that requires immediate intervention beyond nasogastric tube insertion.

Choice B: Iced saline lavage is not a standard procedure for managing peptic ulcer disease (PUD) or its complications. It is not the immediate intervention required for the client's presentation.

Choice C: Administration of pantoprazole (Protonix) IV, a proton pump inhibitor, is a relevant intervention for managing peptic ulcer disease (PUD), but it may not be the most immediate action needed for a client with sudden severe abdominal pain, hypotension, and tachycardia. More urgent interventions are required.

Choice D: Emergency abdominal surgery is the most appropriate and immediate intervention for a client with sudden severe upper abdominal pain, a tender and rigid abdomen, hypotension, and tachycardia. These signs and symptoms may indicate a perforated peptic ulcer, which is a surgical emergency requiring prompt exploration and repair of the perforation to prevent peritonitis and sepsis.

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The nurse is planning a fall prevention program for the residents at a long-term care facility. Which intervention is most important in providing a safe environment?

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Naxlex Comprehensive Predictor Exams

A 37-year-old client diagnosed with chronic kidney disease (CKD) is being treated for renal osteodystrophy. Which nursing diagnosis is most likely to be included in this client's plan of care?

Correct Answer is A

Explanation

Correct Answer is D

Explanation

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Which pathology of autonomic cardiac regulation is mediated by sympathetic innervation?

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