Question

A nurse is admitting a client who is at risk for falls to a medical- surgical unit. Which of the following actions should the nurse take?

Answer 1

Correct Answers:

Provide the client with a night light.

Rationale :

A night light reduces the risk of falls by improving visibility, especially for clients who may need to move at night. It prevents disorientation and allows for safer navigation in an unfamiliar hospital environment.

Distractor Analysis :

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Answer 2

Correct Answers:

The client's belief that his needs will be met through education.

Rationale :

Learning is most effective when a client perceives the information as relevant and beneficial to their personal situation. Internal motivation enhances retention and adherence to self-care instructions.

Distractor Analysis :

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Answer 3

Correct Answers:

"l will use the grab bars when getting in and out of the bathtub."
"l need to have a fire escape plan with my family"
"l need to check my medication expiration dates."

Rationale :

Grab bars, a fire escape plan, and checking medication expiration dates all contribute to home safety by reducing fall risks and ensuring medication safety. These measures help prevent common household accidents and medical errors.

Distractor Analysis :

Rationale for Incorrect Options to be Available Soon

Answer 4

Correct Answers:

"Have you thought about harming yourself?"

Rationale :

Directly assessing suicidal ideation is a key component of mental health assessment and ensures immediate intervention if needed. It allows the nurse to determine the severity of risk and take appropriate action.

Distractor Analysis :

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Answer 5

Correct Answers:

"Have you thought about harming yourself?"

Rationale :

Directly assessing suicidal ideation is a key component of mental health assessment and ensures immediate intervention if needed. It allows the nurse to determine the severity of risk and take appropriate action.

Distractor Analysis :

Rationale for Incorrect Options to be Available Soon

Answer 6

Correct Answers:

"l will perform ankle and knee exercises every hour."

Rationale :

Frequent movement prevents complications of immobility, such as deep vein thrombosis (DVT) and joint stiffness. It promotes circulation and prevents muscle atrophy.

Distractor Analysis :

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Answer 7

Correct Answers:

"The scale measures six elements!'

Rationale :

The Braden scale assesses six key risk factors: sensory perception, moisture, activity, mobility, nutrition, and friction/shear. Understanding these elements helps in preventing pressure injuries.

Distractor Analysis :

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Answer 8

Correct Answers:

"Have you thought about harming yourself?"

Rationale :

Assessing suicidal intent allows the nurse to initiate necessary interventions to protect the client. Immediate evaluation helps determine if the client needs urgent psychiatric care.

Distractor Analysis :

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Answer 9

Correct Answers:

When removing the medication from the medication drawer
Directly before administering the medication
When preparing the medication dosage

Rationale :

Checking medication when removing it, before administering, and while preparing the dosage ensures accuracy and reduces errors. These checks align with the "three checks" principle in medication administration safety.

Distractor Analysis :

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Answer 10

Correct Answers:

Ensure the pouch is 0.32 cm (1/8 in) larger than the stoma.

Rationale :

A properly sized pouch prevents leakage, which can cause skin irritation and breakdown around the stoma. Allowing a small gap ensures that the pouch does not constrict the stoma while still maintaining a secure fit.

Distractor Analysis :

Rationale for Incorrect Options to be Available Soon

QLexNursing

1 : A nurse is admitting a client who is at risk for falls to a medical- surgical unit. Which of the following actions should the nurse take?

2 : A nurse is teaching a client how to self-administer daily low-dose heparin injections. Which of the following factors is most likely to increase the client's motivation to learn?

3 : A home health nurse is teaching a client about home safety.

Which of the following statements by the client indicates an understanding of the teaching? (Select all that apply.)

4 : A nurse in a mental health clinic is caring for an older adult client who has depression and has stopped taking their medication. The client tells the nurse, "l want to die now that my partner is gone."

Which of the following responses should the nurse make?

5 : A nurse in a mental health clinic is caring for an older adult client who has depression and has stopped taking their medication. The client tells the nurse, "l want to die now that my partner is gone."

Which of the following responses should the nurse make?

6 : A nurse is providing teaching to a client about reducing the adverse effects of immobility.

Which of the following statements by the client indicates an understanding of the teaching?

7 : A nurse is teaching a group of newly licensed nurses about the Braden scale. Which of the following responses by a newly licensed nurse indicates an understanding of the teaching?

8 : A nurse in a mental health clinic is caring for an older adult client who has depression and has stopped taking their medication. The client tells the nurse, "l want to die now that my partner is gone."

Which of the following responses should the nurse make?

9 : A nurse is preparing to administer medications to a client. At which of the following times should the nurse compare the medication administration record and the medication label?

(Select all that apply.)

10 : A nurse is caring for a client who has a colostomy. Which of the following actions should the nurse take?

QLexNursing

1 : A nurse is admitting a client who is at risk for falls to a medical- surgical unit. Which of the following actions should the nurse take?

2 : A nurse is teaching a client how to self-administer daily low-dose heparin injections. Which of the following factors is most likely to increase the client's motivation to learn?

3 : A home health nurse is teaching a client about home safety.Which of the following statements by the client indicates an understanding of the teaching? (Select all that apply.)

4 : A nurse in a mental health clinic is caring for an older adult client who has depression and has stopped taking their medication. The client tells the nurse, "l want to die now that my partner is gone."Which of the following responses should the nurse make?

5 : A nurse in a mental health clinic is caring for an older adult client who has depression and has stopped taking their medication. The client tells the nurse, "l want to die now that my partner is gone."Which of the following responses should the nurse make?

6 : A nurse is providing teaching to a client about reducing the adverse effects of immobility.Which of the following statements by the client indicates an understanding of the teaching?

7 : A nurse is teaching a group of newly licensed nurses about the Braden scale. Which of the following responses by a newly licensed nurse indicates an understanding of the teaching?

8 : A nurse in a mental health clinic is caring for an older adult client who has depression and has stopped taking their medication. The client tells the nurse, "l want to die now that my partner is gone."Which of the following responses should the nurse make?

9 : A nurse is preparing to administer medications to a client. At which of the following times should the nurse compare the medication administration record and the medication label?(Select all that apply.)

10 : A nurse is caring for a client who has a colostomy. Which of the following actions should the nurse take?

3 : A home health nurse is teaching a client about home safety.

Which of the following statements by the client indicates an understanding of the teaching? (Select all that apply.)

4 : A nurse in a mental health clinic is caring for an older adult client who has depression and has stopped taking their medication. The client tells the nurse, "l want to die now that my partner is gone."

Which of the following responses should the nurse make?

5 : A nurse in a mental health clinic is caring for an older adult client who has depression and has stopped taking their medication. The client tells the nurse, "l want to die now that my partner is gone."

Which of the following responses should the nurse make?

6 : A nurse is providing teaching to a client about reducing the adverse effects of immobility.

Which of the following statements by the client indicates an understanding of the teaching?

8 : A nurse in a mental health clinic is caring for an older adult client who has depression and has stopped taking their medication. The client tells the nurse, "l want to die now that my partner is gone."

Which of the following responses should the nurse make?

9 : A nurse is preparing to administer medications to a client. At which of the following times should the nurse compare the medication administration record and the medication label?

(Select all that apply.)