The RN performs an admission assessment and determines the client is a fall risk. What is a priority nursing intervention for this client?
Provide a walker.
Place a chair on either side of the bed.
Provide a cane.
Place a fall risk wrist band on the client.
The Correct Answer is D
This is because a fall risk wristband alerts the staff and other caregivers that the client is at risk of falling and needs extra precautions and supervision. A walker, a cane, or a chair on either side of the bed are not priority interventions for a fall risk client, as they do not address the root cause of the problem or prevent potential falls.
Choice A is wrong because a walker may not be appropriate for the client’s condition or mobility level, and it may pose a tripping hazard if not used correctly.
Choice B is wrong because placing a chair on either side of the bed may limit the client’s access to the bed or the bathroom, and it may also create clutter and obstruction in the room.
Choice C is wrong because a cane may not provide enough stability or support for the client, and it may also be difficult to use in narrow spaces or on slippery surfaces.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
The Nurse Practice Act is a law that outlines the legal scope of practice for nursing in each state. It defines the roles, functions, responsibilities and activities that a nurse is educated, competent and authorized to perform. The Nurse Practice Act also establishes the regulatory bodies that create and implement rules and regulations to protect the public.
Choice B. Nursing process is wrong because it is a systematic method of providing nursing care, not a legal document that defines the scope of practice.
Choice C. Code of Ethics is wrong because it is a set of principles that guide the moral and professional conduct of nurses, not a legal document that defines the scope of practice.
Choice D. Facility policies and procedures are wrong because they are specific guidelines for each healthcare organization, not a legal document that defines the scope of practice.
Correct Answer is D
Explanation
McBurney’s point is located one-third of the distance from the right anterior superior iliac spine to the umbilicus. This is where the base of the appendix is attached to the cecum, which is part of the large intestine. When the appendix becomes inflamed or infected, it causes pain in this area.
Choice A is wrong because the left lower quadrant is where the sigmoid colon and part of the small intestine are located.
These organs are not related to appendicitis.
Choice B is wrong because the left upper quadrant is where the stomach, spleen, and part of the pancreas are located.
These organs are also not related to appendicitis.
Choice C is wrong because the right upper quadrant is where the liver, gallbladder, and part of the small intestine are located. These organs can cause pain in this area if they have problems, but not appendicitis
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