Which of the following would be the most appropriate goal for an elderly client with a nursing diagnosis of risk for injury after hip surgery?
Client will remain free from falls throughout their hospital stay.
Client will increase activity tolerance by discharge from the hospital.
Client will demonstrate effective breathing pattern when ambulating throughout hospital stay.
Client will increase mobility by the time of discharge from hospital.
The Correct Answer is A
Choice A reason: Client will remain free from falls throughout their hospital stay is the most appropriate goal for an elderly client with a nursing diagnosis of risk for injury after hip surgery, because it is specific, measurable, attainable, realistic, and timely. This goal addresses the main risk factor for injury, which is falling, and the main outcome indicator, which is the absence of falls. This goal also reflects the client's condition, needs, and preferences, and is consistent with the standards of care and evidencebased practice.
Choice B reason: Client will increase activity tolerance by discharge from the hospital is not the most appropriate goal for an elderly client with a nursing diagnosis of risk for injury after hip surgery, because it is vague, subjective, unachievable, unrealistic, and untimely. This goal does not address the main risk factor for injury, which is falling, nor the main outcome indicator, which is the absence of falls. This goal also does not reflect the client's condition, needs, and preferences, and is not consistent with the standards of care and evidencebased practice.
Choice C reason: Client will demonstrate effective breathing pattern when ambulating throughout hospital stay is not the most appropriate goal for an elderly client with a nursing diagnosis of risk for injury after hip surgery, because it is irrelevant, unrelated, unnecessary, unrealistic, and untimely. This goal does not address the main risk factor for injury, which is falling, nor the main outcome indicator, which is the absence of falls. This goal also does not reflect the client's condition, needs, and preferences, and is not consistent with the standards of care and evidencebased practice.
Choice D reason: Client will increase mobility by the time of discharge from hospital is not the most appropriate goal for an elderly client with a nursing diagnosis of risk for injury after hip surgery, because it is vague, subjective, unachievable, unrealistic, and untimely. This goal does not address the main risk factor for injury, which is falling, nor the main outcome indicator, which is the absence of falls. This goal also does not reflect the client's condition, needs, and preferences, and is not consistent with the standards of care and evidencebased practice.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A reason: "I will need to limit the number of fruit servings each day." is not a statement that indicates a correct understanding of the teaching, because it is irrelevant and inaccurate. Limiting the number of fruit servings each day is not a part of the lowpurine diet, as fruits are low in purine and do not affect the uric acid levels. Fruits are also beneficial for the health, as they provide vitamins, antioxidants, and fiber.
Choice B reason: "I should avoid eating liver and other organ meats." is a statement that indicates a correct understanding of the teaching, because it is relevant and accurate. Avoiding eating liver and other organ meats is a part of the lowpurine diet, as organ meats are high in purine and can increase the uric acid levels. Uric acid is a waste product that is formed when purine is broken down in the body. High uric acid levels can cause gout, which is a type of arthritis that occurs when uric acid crystals accumulate in the joints, causing pain, inflammation, and swelling.
Choice C reason: "I can drink only white wine." is not a statement that indicates a correct understanding of the teaching, because it is incorrect and misleading. Drinking only white wine is not a part of the lowpurine diet, as white wine is not low in purine and can increase the uric acid levels. Alcohol, in general, can interfere with the excretion of uric acid by the kidneys, and can also trigger or worsen the gout attacks. Therefore, people with gout should limit or avoid alcohol consumption, regardless of the type or color of the wine.
Choice D reason: "I should choose red meat instead of poultry." is not a statement that indicates a correct understanding of the teaching, because it is incorrect and misleading. Choosing red meat instead of poultry is not a part of the lowpurine diet, as red meat is not low in purine and can increase the uric acid levels. Red meat, such as beef, pork, or lamb, is high in purine and can aggravate the gout symptoms. Therefore, people with gout should limit or avoid red meat consumption, and choose poultry, fish, or plantbased proteins instead.
Correct Answer is A
Explanation
Choice A reason: Using standard precautions is a practice that is recommended to prevent HIV transmission, because it is a set of guidelines that apply to all clients, regardless of their infection status, and that aim to prevent the exposure to blood, body fluids, or other potentially infectious materials. Standard precautions include hand hygiene, use of personal protective equipment, safe handling and disposal of sharps, environmental cleaning, and respiratory hygiene.
Choice B reason: Double gloving is not a practice that is recommended to prevent HIV transmission, because it is not proven to be more effective or safer than single gloving. Double gloving is a technique that involves wearing two pairs of gloves, one over the other, which may provide some extra protection against needlestick injuries or glove punctures, but may also reduce the tactile sensitivity, dexterity, or comfort of the wearer. Double gloving is not a routine practice, but rather an option for certain situations, such as highrisk procedures, long surgeries, or known HIVpositive clients.
Choice C reason: Applying hand sanitizer to gloves during cares is not a practice that is recommended to prevent HIV transmission, because it is not appropriate or hygienic. Applying hand sanitizer to gloves during cares is a practice that can damage the integrity and effectiveness of the gloves, as the alcohol or other chemicals can degrade the material, cause holes, or reduce the fit of the gloves. Applying hand sanitizer to gloves during cares can also create a false sense of security, as the gloves may still be contaminated or ineffective. Hand sanitizer should be applied to the hands before and after wearing gloves, not to the gloves themselves.
Choice D reason: Wearing a mask within three feet of the client is not a practice that is recommended to prevent HIV transmission, because it is not necessary or relevant. Wearing a mask within three feet of the client is a practice that is part of the droplet precautions, which are used to prevent the transmission of infections that are spread by large respiratory droplets, such as influenza, pertussis, or meningitis. HIV is not transmitted by respiratory droplets, but rather by sexual contact, blood, or other body fluids. Wearing a mask within three feet of the client may not provide any protection against HIV, and may also cause stigma or discrimination.
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