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","C","E"]
Explanation
Choice A reason: Obtaining a PAPR mask is not a step in preparing a sterile field. A PAPR mask is a powered airpurifying respirator that protects the wearer from airborne contaminants. It is not required for setting up a sterile field, unless the client has a highly infectious disease.
Choice B reason: Do not turn away from the sterile field is a step in preparing a sterile field. Turning away from the sterile field can contaminate the field or the items on it. The nurse should always face the sterile field and keep it in view.
Choice C reason: Add items to the sterile field by dropping them gently is a step in preparing a sterile field. Dropping items gently onto the sterile field prevents splashing or touching the field or the items. The nurse should open the sterile packages away from the field and drop the items close to the edge of the field.
Choice D reason: Covering the sterile field once it is set up is not a step in preparing a sterile field. Covering the sterile field can compromise its sterility and create moisture that can harbor microorganisms. The nurse should not cover the sterile field unless it is necessary to move it or store it for later use.
Choice E reason: Preparing the client before setting up the sterile field is a step in preparing a sterile field. Preparing the client involves explaining the procedure, obtaining consent, providing privacy, and positioning the client. The nurse should prepare the client before setting up the sterile field to avoid leaving the field unattended or exposing it to the client's body fluids.
Correct Answer is A
Explanation
Choice A reason: Shearing or friction is the force that caused the injury, because it occurs when the skin and underlying tissues move in opposite directions, such as when the client slides down in bed. Shearing or friction can damage the blood vessels and reduce blood flow to the skin, resulting in tissue ischemia, necrosis, and ulceration.
Choice B reason: Pressure or gravity is not the force that caused the injury, because it occurs when the skin and underlying tissues are compressed between a bony prominence and an external surface, such as when the client lies on his back. Pressure or gravity can impair blood flow and oxygen delivery to the skin, resulting in tissue damage and ulceration.
Choice C reason: Chemical or pressure is not the force that caused the injury, because it occurs when the skin is exposed to a substance that causes irritation, inflammation, or corrosion, such as when the client has a wound dressing that contains an antiseptic or a topical agent. Chemical or pressure can damage the skin barrier and increase the risk of infection and delayed wound healing.
Choice D reason: Twisting and bending is not the force that caused the injury, because it occurs when the skin and underlying tissues are stretched or distorted, such as when the client twists his ankle or bends his knee. Twisting and bending can cause sprains, strains, or tears of the ligaments, tendons, or muscles.
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