Question

A nurse is creating a plan of care for a client who is at risk for falls. Which of the following interventions should the nurse include in the plan?

Answer 1

Correct Answers:

Have the client demonstrate the use of the call light

Rationale :

🟢 Teaching the client to demonstrate proper call light use ensures they understand how to summon assistance when needed, which is a critical intervention in fall prevention.

🟢 This intervention empowers the client to actively participate in their safety by seeking help before attempting unsafe movements.

🟢 Proper use of the call light reduces unsupervised ambulation, which is one of the most common causes of inpatient falls.

🟢 It also allows the nurse to assess the client’s cognitive ability and readiness to follow safety instructions.

🟢 Compared to bed adjustments or placing items far away, ensuring call light use directly addresses timely assistance and supervision.

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Answer 2

Correct Answers:

Bend one knee and have the client lean into the nurse's opposite leg.

Rationale :

🔵 The safest way to assist a falling client is to gently guide the fall by bending one knee and allowing the client to lean against the nurse’s leg.

🔵 This maneuver lowers the client’s center of gravity and uses the nurse’s leg as a supportive barrier, minimizing injury.

🔵 It prevents sudden pulling on the client’s body, which could cause joint or skin injury.

🔵 The technique also protects the nurse’s back from strain by using proper body mechanics.

🔵 Lowering the client in a controlled manner reduces the likelihood of serious trauma, such as head injury or fractures.

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Answer 3

Correct Answers:

The provide name

Rationale :

✔️ To safely administer medications, the nurse must follow the two-client identifiers rule (such as full name and date of birth), never relying on room number, address, or phone number.

✔️ The client’s name as provided by the healthcare provider order and verified with the client’s ID band ensures that the correct patient receives the correct medication.

✔️ Using the provider’s name or room number would increase the risk of medication errors, since multiple clients may share providers or be in adjacent rooms.

✔️ This practice aligns with The Joint Commission’s National Patient Safety Goals, which emphasize client identification before procedures and medication administration.

✔️ Proper identification prevents sentinel events and reinforces safe medication practices within nursing care.

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Answer 4

Correct Answers:

Route of administration

Rationale :

🟢 Every medication order must include the five essential components: client’s name, medication name, dosage, route, and frequency.

🟢 In this order, the route of administration is missing; insulin can be given via subcutaneous injection, IV, or insulin pump, so it must be specified to prevent medication errors.

🟢 The medication name (regular insulin), dose (12 units), and timing (before meals) are all clearly stated and appropriate.

🟢 Clarifying the route ensures correct administration and prevents adverse outcomes, especially since IV insulin has a much stronger and faster effect than subcutaneous insulin.

🟢 Nursing safety practice requires contacting the provider to resolve any ambiguity before carrying out the order.

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Answer 5

Correct Answers:

Reports pain as a 5on a scale of 0 to 10

Rationale :

🔹 Moderate pain (5/10) two days after a total knee arthroplasty indicates the client’s pain management plan is insufficient and should be modified.

🔹 Uncontrolled pain can limit mobility, interfere with deep breathing, and delay participation in physical therapy, which is essential for recovery.

🔹 Persistent pain can increase stress response, elevate blood pressure, and impair wound healing, making adequate pain control a priority.

🔹 Pain at this level may require reassessment of the analgesic regimen, use of multimodal pain management, or non-pharmacologic interventions.

🔹 The other findings (use of walker, incentive spirometer, flatus) indicate appropriate recovery progress and do not require modification of the care plan

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Answer 6

Correct Answers:

An obturator

Rationale :

🔵 An obturator is the most essential piece of equipment to keep at the bedside of a client with a new tracheostomy because it is required to reinsert the tracheostomy tube if it becomes dislodged.

🔵 Early after surgery, the tracheostomy tract is not well established, and accidental decannulation can quickly lead to airway compromise if reinsertion cannot be performed immediately.

🔵 Having the obturator readily available ensures that the nurse or provider can act quickly to maintain airway patency in an emergency.

🔵 Other equipment listed (incentive spirometer, CPAP, nasal cannula) may be useful for respiratory support but do not address the critical airway security needs of a new tracheostomy.

🔵 Airway protection is the nurse’s top priority for tracheostomy clients, making the obturator indispensable at the bedside.

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Answer 7

Correct Answers:

"Contrast dye will be used for this test."

Rationale :

🟠 An intravenous pyelogram (IVP) is a diagnostic imaging test that uses iodine-based contrast dye injected intravenously to visualize the kidneys, ureters, and bladder.

🟠 The dye highlights the urinary tract structures on X-ray images, helping detect obstructions, stones, tumors, or structural abnormalities.

🟠 The client should be informed about potential risks, such as allergic reactions to iodine or contrast-induced nephropathy, making pre-assessment of allergies and kidney function essential.

🟠 No restriction of fluids is required afterward; instead, increased fluid intake is encouraged to help flush the dye from the body.

🟠 Unlike cystoscopy, no camera is inserted into the urethra, and hematuria (pink urine) is not expected after IVP.

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Answer 8

Correct Answers:

Delegating a PN to insert an indwelling urinary catheter

Rationale :

🟡 A practical nurse (PN) is trained and licensed to perform invasive sterile procedures, such as inserting an indwelling urinary catheter, making this an appropriate delegation.

🟡 The RN retains responsibility for the care plan and initial assessments, but PNs can perform routine procedures and certain medication administrations under delegation.

🟡 Delegating an initial assessment is not appropriate because only an RN can perform comprehensive admission assessments and develop nursing diagnoses.

🟡 An AP can take routine vital signs and provide feeding, but not in high-risk scenarios like immediately post-surgery or feeding a client with dysphagia due to aspiration risk—these require RN or PN oversight.

🟡 Understanding the “five rights of delegation” (right task, circumstance, person, direction/communication, supervision/evaluation) ensures safe, effective delegation practices

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Answer 9

Correct Answers:

Sit at the same level as the client.

Rationale :

🔹 Sitting at the same level ensures the client can clearly see the nurse’s facial expressions and lip movements, which improves understanding.

🔹 This position promotes effective communication and reduces strain for the client when trying to follow along.

🔹 Repeating information verbatim is less effective; instead, the nurse should rephrase if the client does not understand.

🔹 Hand gestures and visual cues are actually helpful for communication with hearing-impaired clients.

🔹 Raising the tone of voice often distorts sound and makes it harder to interpret speech, so a calm, clear tone is preferred.

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Answer 10

Correct Answers:

Decrease in respiratory rate

Rationale :

🔵 A decrease in respiratory rate is a classic sign of the relaxation response produced by meditation, reflecting reduced sympathetic nervous system activity.

🔵 Meditation promotes parasympathetic activation, leading to slower, deeper breathing and improved oxygen exchange.

🔵 This physiologic change helps reduce stress, anxiety, and tension, which are common therapeutic goals of meditation.

🔵 Unlike increased blood pressure or stiff muscles, meditation usually results in lower blood pressure, reduced muscle tension, and improved calmness.

🔵 Improved focus and concentration are additional benefits; a decrease in ability to focus would not indicate a therapeutic response.

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QLexNursing

1 :
A nurse is creating a plan of care for a client who is at risk for falls. Which of the following interventions should the nurse include in the plan?

2 :
A nurse is assisting a client in ambulating to the bathroom when the client begins to fall. Which of the following actions should the nurse take?

3 :
A nurse is preparing to administer medications to a client. Which of the following information should the nurse use to verify the client's identity?

4 :
A nurse is reviewing a new prescription from a provider that reads: regular insulin 12 units before meals. Which of the following parts of the prescription should the nurse clarify with the provider?

5 :
A nurse is caring for a client who is 2 days postoperative following a total knee arthroplasty. Which of the following findings indicates that the nurse should modify the client's plan of care?

6 :
A nurse is caring for a client who has a new tracheostomy. The nurse should ensure that which of the following pieces of equipment is present in the client's room?

7 :
A nurse is teaching a client who is scheduled for an intravenous pyelogram. The nurse should identify that which of the following client statements indicates an understanding of the procedure?

8 :
A nurse manager is teaching about the rights of delegation to assistive personnel (AP) and practical nurses (PN). Which of the following examples should the nurse manager include in the teaching?

9 :
A nurse is communicating with a client who has hearing loss. Which of the following actions should the nurse take?

10 :
A nurse is assessing a client who has completed a session of meditation. Which of the following findings indicates a therapeutic response to this therapy?

QLexNursing

1 : A nurse is creating a plan of care for a client who is at risk for falls. Which of the following interventions should the nurse include in the plan?

2 : A nurse is assisting a client in ambulating to the bathroom when the client begins to fall. Which of the following actions should the nurse take?

3 : A nurse is preparing to administer medications to a client. Which of the following information should the nurse use to verify the client's identity?

4 : A nurse is reviewing a new prescription from a provider that reads: regular insulin 12 units before meals. Which of the following parts of the prescription should the nurse clarify with the provider?

5 : A nurse is caring for a client who is 2 days postoperative following a total knee arthroplasty. Which of the following findings indicates that the nurse should modify the client's plan of care?

6 : A nurse is caring for a client who has a new tracheostomy. The nurse should ensure that which of the following pieces of equipment is present in the client's room?

7 : A nurse is teaching a client who is scheduled for an intravenous pyelogram. The nurse should identify that which of the following client statements indicates an understanding of the procedure?

8 : A nurse manager is teaching about the rights of delegation to assistive personnel (AP) and practical nurses (PN). Which of the following examples should the nurse manager include in the teaching?

9 : A nurse is communicating with a client who has hearing loss. Which of the following actions should the nurse take?

10 : A nurse is assessing a client who has completed a session of meditation. Which of the following findings indicates a therapeutic response to this therapy?

1 :
A nurse is creating a plan of care for a client who is at risk for falls. Which of the following interventions should the nurse include in the plan?

2 :
A nurse is assisting a client in ambulating to the bathroom when the client begins to fall. Which of the following actions should the nurse take?

3 :
A nurse is preparing to administer medications to a client. Which of the following information should the nurse use to verify the client's identity?

4 :
A nurse is reviewing a new prescription from a provider that reads: regular insulin 12 units before meals. Which of the following parts of the prescription should the nurse clarify with the provider?

5 :
A nurse is caring for a client who is 2 days postoperative following a total knee arthroplasty. Which of the following findings indicates that the nurse should modify the client's plan of care?

6 :
A nurse is caring for a client who has a new tracheostomy. The nurse should ensure that which of the following pieces of equipment is present in the client's room?

7 :
A nurse is teaching a client who is scheduled for an intravenous pyelogram. The nurse should identify that which of the following client statements indicates an understanding of the procedure?

8 :
A nurse manager is teaching about the rights of delegation to assistive personnel (AP) and practical nurses (PN). Which of the following examples should the nurse manager include in the teaching?

9 :
A nurse is communicating with a client who has hearing loss. Which of the following actions should the nurse take?

10 :
A nurse is assessing a client who has completed a session of meditation. Which of the following findings indicates a therapeutic response to this therapy?