Which of the following clients should be considered a priority for immediate assessment and intervention?

A client who has epidural analgesia and weakness in the lower extremities

A client who has diabetes mellitus and an HbA1c of 7.2% (less than 79%).

A client who has sinus arrhythmia and is receiving cardiac monitoring.

A client who has a hip fracture and a new onset of tachypnea.

Answer and Explanation

The Correct Answer is D

A. A client who has epidural analgesia and weakness in the lower extremities: Lower extremity weakness can be a side effect of epidural analgesia. While it requires monitoring, it is typically not immediately life-threatening unless accompanied by other neurological changes.

B. A client who has diabetes mellitus and an HbA1c of 7.2%: An HbA1c of 7.2% indicates slightly above-target blood glucose control. This is a chronic management concern and does not require immediate intervention.

C. A client who has sinus arrhythmia and is receiving cardiac monitoring: Sinus arrhythmia is often a benign, expected finding, particularly in children or young adults. Continuous monitoring is appropriate, but it is not an emergent concern.

D. A client who has a hip fracture and a new onset of tachypnea: New-onset tachypnea in a client with a hip fracture can indicate a serious complication such as pulmonary embolism or fat embolism syndrome. This requires immediate assessment and intervention.

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Correct Answer is D

Explanation

A. Patient-centered care: This competency focuses on respecting client preferences, values, and needs while involving them in care decisions. Completing an incident report does not directly address individualized client care.

B. Evidence-based practice: Evidence-based practice involves integrating the best current research evidence with clinical expertise and patient values. Documenting an incident report is not based on reviewing or applying research evidence.

C. Informatics: Informatics involves using information technology to communicate, manage knowledge, and support decision-making. While an incident report may use electronic systems, the primary purpose is not focused on informatics competency.

D. Quality improvement: Completing an incident report identifies errors, near misses, or adverse events, which helps the healthcare team analyze processes and implement changes to improve patient safety. This reflects the quality improvement competency by contributing to safer care systems.

A. Prescribed medication B. Blood pressure readings C. Gait D. Reports of home environment E. Voiding pattern

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

Explanation

Rationale for correct choices:

Prescribed medication: The client is taking hydrochlorothiazide, a diuretic that can cause dizziness, orthostatic hypotension, and increased nighttime urination. These side effects increase the risk for falls, especially in older adults who may already have mobility limitations.
Blood pressure readings: The client’s blood pressure dropped from sitting 138/84 mm Hg to standing 100/70 mm Hg, indicating orthostatic hypotension. This sudden decrease in blood pressure can cause lightheadedness, dizziness, or fainting, all of which increase the likelihood of falls.
Voiding pattern: The client reports waking 2–3 times per night to void. Nocturia increases fall risk because the client must get up in low-light conditions, potentially while drowsy, making them more susceptible to tripping or losing balance.

Rationale for incorrect choices:

Gait: The client’s gait is steady, and no abnormalities were noted during assessment. While gait disturbances can increase fall risk, in this case, the client’s mobility does not currently contribute to risk.
Reports of home environment: The client has already removed throw rugs and increased lighting, implementing effective fall prevention strategies at home. Therefore, the home environment does not currently place the client at increased risk for falls.

View Question and Answer

A nursery nurse is attending the birth of a post-term infant.

Exhibits

Drag words from the choices below to fill in each blank in the following sentence.

Upon review of the medical record, the nurse should determine the infant newborn is at risk for developing

and .

View Question and Answer

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Which of the following clients should be considered a priority for immediate assessment and intervention?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is completing an incident report after a client fall. Which of the following competencies of Quality and Safety Education for Nurses is the nurse demonstrating?

Correct Answer is D

Explanation

A nurse in a provider's office is caring for a client. Exhibits The nurse is performing a fall risk assessment for the client. Select the 3 findings that place the client at risk for a fall.

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

Explanation

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A nursery nurse is attending the birth of a post-term infant. Exhibits Drag words from the choices below to fill in each blank in the following sentence. Upon review of the medical record, the nurse should determine the infant newborn is at risk for developing dropdown and dropdown.

A nurse is preparing to administer eye drops to a school-age child. Identify the actions the nurse should take. (Move the steps into the box on the right, placing them in the order of performance. Use all the steps.)