A client brings several electronic devices to a nursing home. One of the devices has a two-pronged plug. Which rationale should the nurse provide when explaining why an electrical device must have a three-pronged plug?
controls stray electrical currents (acts as a ground)
A nurse is caring for caring for a client with Parkinson's disease who is experiencing difficulty swallowing. For which major potential problem associated with dysphagia should the nurse assess the client?
Aspiration
A nurse is caring for a confused client. Which should the nurse do to prevent this client from falling?
Maintain close supervision
A school nurse is teaching children about fire safety procedures. What is the first thing they should be taught to do if their clothes catch on fire?
roll on the ground
A primary health care provider prescribes a vest restraint for a client. Which should the nurse do first when applying this restraint?
Perform an inspection of the client's skin where the restraint is to be placed.
An unconscious client begins vomiting. In which position should the nurse place the client?
Side-lying
A toaster is on fire in the pantry of a hospital unit. What should the nurse do first?
Activate the fire alarm
The risk management coordinator is preparing a program on the factors that contribute to falls in the hospital setting. Which factor that most often contributes to falls should be included in the program?
Advanced age of clients
A nurse is assessing a client who is being admitted to the hospital. Which is the most important information that indicates whether the client is at risk for physical injury?
Two recent falls that occurred at home
Which should the nurse do to best prevent a client from falling?
Assist the client with ambulation
Which is the last in making an occupied bed that nurse should teach a nursing assistant?
Lowering the height of the bed toward the floor
A nurse is caring for a patient for a client with a nasogastric tube for gastric decompression. Which nursing action takes priority?
Positioning the client in the semi-fowler position.
A family member brings an electric radio to a client in a long-term care facility. The client tells the nurse than an electric shock was felt while turning on the radio. Which should the nurse do first?
Take the client's apical pulse
A nurse educator is teaching a group of newly hired nursing assistants. Which hospitalized client should they be taught is at the highest risk for injury?
Confused middle age man
A nurse in the nursing education department of a community hospital is planning an inservice education class about injury prevention. Which factor that most commonly causes physical injuries in hospitalized clients should be included in the teaching plan?
Falls
Which is the priority nursing intervention to prevent client problems associated with latex allergies?
Identify persons at risk
Which nursing interventions enhances an older adult's sensory perception and thereby helps prevent injury when walking from the bed to the bathroom?
Providing adequate lightinh
A nurse is preparing a client for a physical examination. Which is most important for the nurse to do in this situation?
Identify the positions contraindicated for the client during the examination.
A client has dysphagia. Which nursing action takes priority when feeding thus client?
Checking the mouth for emptying between every bite
A 3 year old child is admitted to the pediatric unit. Which should the nurse do to maintain the safety of this preschool-age child?
Ensure the child is under continuous supervision
A nurse is caring for a client with dementia. Which time of day is of most concern for the nurse when trying to protect this client from injury?
Night
A nurse is orienting a newly admitted client to the hospital. Which is the most important for the nurse to teach the client how to do?
Notify the nurse when help is needed
Profuse smoke is coming out of the heating unit in a patient's room. What should the nurse do first?
Move the client out of the room
The nurse must apply a hospital gown that does not have snaps on the shoulders to a patient receiving an intravenous infusion in the forearm. What should the nurse do?
Insert the client's IV bag and tubing through the sleeve from inside of the gown first
A nurse is planning care for a client with a wrist restraint. How often should a restraint be removed, the area massaged, and the joints moved through through their full range?
Every 2 hours
A home-care nurse is assigned to care for an older adult living at home. Which is the first action the home-care nurse should employ to prevent falls by this older adult?
Conduct a comprehensive risk assessment
A nurse is preparing a bed to receive a newly admitted client to the hospital. Which action is the most important?
Ensuring that the bed wheels are locked
Which is an appropriately worded goal for a client who is at risk for falling? Select all that apply.
The client will be able from a bet to a chair safely while hospitalized.
The client will be free from trauma
A nurse is caring for a client who has a prescription for a mitt restraint. Place an X where the mitt restraint strap should be secured with a quick-release knot
X should be on the frame of the bed
Which intervention should a nurse implement when assisting a client to use a bedpan? Select all that apply
Encourage the client to help as much as possible when using the bedpan.
Position the rounded rim of the bedpan under the clients buttocks
Raise the head of the bed to the semi-fowler position once the client is placed on the bedpan
A nurse identifies the presence of smoke exiting the door to the dirty utility room. Place the nurse actions in order of priority using the race model.
Pull the fire alarm
Close unit doors and windows
Shut the door to the utility room
Provide emotional support to agitated clients
Which clinical manifestation indicates that a further nursing assessment is necessary to determine if the client is having difficulty swallowing. Select all that apply
Noisy breathing
Debris in the buccal cavity
Coughing episodes
Slurred speech
Drooling
A male client is admitted to ambulatory case for bilateral herniorrhaphy. A nurse on the unit interviews the client, obtains the client's vital signs, and reviews the primary health care provider's prescriptions. What should the nurse do first?
Ensure the client's allergy band includes the client's identified allergies
A nurse is planning care for a client who requires bilateral arm restraints because the client is delirious and attempting to pull out a urinary retention catheter. Which information is important when planning care for this client? Select all that apply
Laws permit the use of restraints when specific guidelines are followed
Reasons for use of restraints must be clearly documented.
A nurse is implementing the action demonstrated is illustration. Which is the nurse doing?
Dislodging an object from a client's airway
An adult client consistently tries to pull out a nasogastric tube. As a last resort to maintain integrity of the tube and client safety, the nurse obtains a prescription for a restraint. Which type of restraint is appropriate in this situation? Select all
Elbow restraint
Wrist restraint
Mitt restraint
A nurse uses the get up and go test to assess a client for weakness, poor balance, and decreased flexibility. Place the following actions in the order in which they should be implemented when employing the Get Up and Go Test
Sit in a Chair
Ask the client to stand
Close the eyes
Open the yes
Walk 10 feet and then return to the chair
Which action is important when the nurse uses a stretcher? Select all that apply
Pushing the stretcher from the end with the end of the client's head
Which human response to illness alerts the nurse that a client is at risk for aspiration during meals?
Dysphagia
Letheragy
Stomatitis
A nurse is caring for a client with a moderate problem with balance. Place an X over the cane that is most appropriate for this client.
quad cane (four prongs)