Nursing Chapter 32 Rationale The Nurse Should Apply The Padded

Question 19

Type: MCSA

The nurse is admitting an older client to the care area. What can the nurse do to promote a safe environment for

the client?

1. Keep clutter to a minimum in the client’s room.

2. Have the client wear terry-cloth slippers.

3. Provide adequate lighting.

4. Turn off alarms to reduce noise.

Question 20

Type: MCMA

The nurse is determining a client’s risk for injury. What should the nurse assess in this client?

Standard Text: Select all that apply.

1. Age

2. Mobility

3. Hearing

4. Vision

5. Dietary intake

Question 21

Type: MCMA

An older client is observed having difficulty moving from a sitting to standing position, and has an unsteady gait.

What should the nurse assess in this client to promote home safety?

Standard Text: Select all that apply.

1. Presence of grab bars in the bathroom

2. Absence of scatter rugs on the floors

3. Correct use of cane to ambulate

4. Ability to stand in place for a minute before ambulating

5. Alcohol use with prescribed medications

Question 22

Type: MCSA

A client is being transferred from an acute care facility to a long-term care facility. What information should the

nurse provide to the long-term care facility about the client’s medications?

1. Nothing, as the medications all need to be reordered at the long-term care facility.

2. Have the client’s medication prescriptions filled before going to long-term care facility.

3. Instruct the client to tell the nurses at the long-term care facility what medications are prescribed.

4. Inform the nurse at the long-term care facility what medications the client is prescribed, and document that this

information was provided.

Question 23

Type: MCSA

A client is prescribed seizure precautions. The nurse places functioning oral suction equipment in the client’s

room for what reason?

1. Suctioning might be needed to prevent the aspiration of oral secretions.

2. The client has difficulty swallowing liquids.

3. There was a spare oral suction set up, and the nurse did not want to return it to the engineering department.

4. It helps when the client is brushing her teeth.

Question 24

Type: MCSA

The nurse is evaluating teaching provided to a client about home safety. Which observation indicates that teaching

has been effective?

1. Smoke alarm functioning with new batteries installed

2. Scatter rugs located in the kitchen and bathroom only

3. Cord for a space heater stretched across a hallway

4. Light bulbs burned out in the bathroom and living room

Question 25

Type: MCSA

The nurse is installing a bed safety-monitoring device for a client. What should the nurse do after testing the

device and alarm sound?

1. Place the leg band on the client with the leg in a straight horizontal position.

2. Place the sensor under the mattress near the shoulder region.

3. Set a time delay for 30 seconds.

4. Connect the sensor pad to the control unit.

Question 26

Type: SEQ

A client is prescribed to have wrist restraints applied. Place in order the steps the nurse will take to apply these

restraints.

Standard Text: Click and drag the options below to move them up or down.

Choice 1. Pad bony prominences on the wrist.

Choice 2. Apply the padded portion of the restraint around the wrist.

Choice 3. Pull the tie of the restraint through the slit in the wrist restraint and ensure that it is not too tight.

Choice 4. Attach the other end of the restraint to the movable portion of the bed frame using a half-bow knot.

Question 27

Type: MCSA

The nurse is identifying activities and skills to delegate to unlicensed assistive personnel (UAP). Which action can

the nurse safely delegate?

1. Provide oral fluids to a newly extubated client.

2. Irrigate the indwelling urinary catheter of a client recovering from prostate surgery.

3. Apply a wrist restraint to a client.

4. Administer oral pain medication to a client before the client attends physical therapy.

Question 28

Type: MCSA

A client is prescribed seizure precautions. What can the nurse safely delegate to UAP to complete when

implementing the precautions?

1. Placing a tongue blade at the head of the bed

2. Padding the client’s bed

3. Installing oxygen

4. Checking the oral suction apparatus

Question 29

Type: MCSA

After ambulating a client to the bathroom, the unlicensed assistive personnel did not reattach the client’s bed

safety-monitoring device, and the client fell out of bed. What should the nurse document?

1. Client fell out of bed; bed safety-monitoring device malfunctioning.

2. Client fell out of bed; client removed leg band of bed safety-monitoring device.

3. Client fell out of bed; no observable injuries.

4. Client fell out of bed; bed safety-monitoring device not activated.

Question 30

Type: MCMA

A client who is on seizure precautions experiences a seizure while ambulating in the room. What should the nurse

include in this client’s documentation?

Standard Text: Select all that apply.

1. Who assisted the client back to bed

2. Location of the seizure

3. Duration of the seizure

4. Status of airway and use of oxygen

5. Who discovered the client

Question 31

Type: MCMA

The nurse is preparing to assess a client who has a history of falls. Which methods should the nurse use to assess

this client’s risk for injury?

Standard Text: Select all that apply.

1. Cognitive awareness

2. Mobility

3. Nursing history

4. Physical examination

5. Health status

Question 32

Type: MCMA

The nurse is appointed to be a member of committee whose focus is to identify and address workplace safety

issues. Which issues should the nurse recommend for analysis by this committee?

Standard Text: Select all that apply.

1. Lifting clients

2. Inadequate lighting

3. Bending and walking

4. Exposure to infectious agents

5. Exposure to hazardous medications

Question 33

Type: MCMA

During a home visit, the nurse determines that a toddler is at risk for injury. What did the nurse assess to identify

this client’s risk?

Standard Text: Select all that apply.

1. Unscreened windows

2. Electrical outlets uncovered

3. Yard with a built-in pool unfenced

4. Cleaning solution in the bottom cabinet

5. Pots on stove with handles turned inward