1
A nurse is assessing an older adult
clients risk for falls. Which of the
following assessments should the nurse
use to identify the clients safety needs?
- -Correct answer--Pupil clarity
Visual fields
Visual acuity
A nurse is responding to a call light and
finds a client lying on the bathroom
1
, 2
floor. Which of the following actions
should the nurse take first? - -Correct
answer--Check the client for injuries
A nurse is initiating a protective
environment for a client who has an
allogenic stem cell transplant. Which of
the following precautions should the
nurse plan for the client. - -Correct
answer--Make sure the client wears a
mask when outside her room if there is
construction in the area.
A nurse on a medical-surgical unit is
caring for a client who has a new
2
, 3
prescription for wrist restraints. Which
of the following actions should the nurse
take? - -Correct answer--Pad the
client's wrist before applying the
restraints.
A nurse is caring for a client who is
postoperative and is exhibiting signs of
hemorrhagic shock. The nurse notifies
the surgeon, who tells the nurse to
continue to measure the clients vital
signs every 15 minutes and report back
in 1 hour. Which of the following actions
should the nurse take?
3
, 4
Document the providers statement in
medical records.
Complete an incident report.
Consult The facilities risk manager
Notify the nursing manager - -Correct
answer--Notify the nurse manager
A nurse is preparing to administer
enoxaparin subcutaneous to a client.
Which of the following actions should
the nurse take?
Administer the meds with the needle at
a 45 degree angle
4
A nurse is assessing an older adult
clients risk for falls. Which of the
following assessments should the nurse
use to identify the clients safety needs?
- -Correct answer--Pupil clarity
Visual fields
Visual acuity
A nurse is responding to a call light and
finds a client lying on the bathroom
1
, 2
floor. Which of the following actions
should the nurse take first? - -Correct
answer--Check the client for injuries
A nurse is initiating a protective
environment for a client who has an
allogenic stem cell transplant. Which of
the following precautions should the
nurse plan for the client. - -Correct
answer--Make sure the client wears a
mask when outside her room if there is
construction in the area.
A nurse on a medical-surgical unit is
caring for a client who has a new
2
, 3
prescription for wrist restraints. Which
of the following actions should the nurse
take? - -Correct answer--Pad the
client's wrist before applying the
restraints.
A nurse is caring for a client who is
postoperative and is exhibiting signs of
hemorrhagic shock. The nurse notifies
the surgeon, who tells the nurse to
continue to measure the clients vital
signs every 15 minutes and report back
in 1 hour. Which of the following actions
should the nurse take?
3
, 4
Document the providers statement in
medical records.
Complete an incident report.
Consult The facilities risk manager
Notify the nursing manager - -Correct
answer--Notify the nurse manager
A nurse is preparing to administer
enoxaparin subcutaneous to a client.
Which of the following actions should
the nurse take?
Administer the meds with the needle at
a 45 degree angle
4
