Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice 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?
A. Elevate full-length side rails on both sides of the client's bed.
Elevating full-length side rails on both sides of the client's bed is not recommended, as it can increase the risk of injury if the client tries to climb over them or gets trapped between them.
B. Place the bedside table 0.9 m (3 feet) away from the bed.
Placing the bedside table 0.9 m away is unrelated to fall prevention.
C. Provide the client with a night light.
A night light can help the client see better in the dark and avoid tripping or falling over objects.
D. Keep the client's room temperature at 18° C (64.4" F).
Maintaining the room temperature is important for comfort but doesn't directly prevent falls.
This question is an excerpt from Nurse Dive's nursing test bank - ATI RN FUNDAMENTALS 2023 PROCTORED EXAM. Take the full exam now
Full Explanation
A. Elevating full-length side rails on both sides of the client's bed is not recommended, as it can increase the risk of injury if the client tries to climb over them or gets trapped between them.
B. Placing the bedside table 0.9 m away is unrelated to fall prevention.
C. A night light can help the client see better in the dark and avoid tripping or falling over objects.
D. Maintaining the room temperature is important for comfort but doesn't directly prevent falls.
Similar Questions
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?
A. The nurse explaining the need for education to the client.
While it's important for the nurse to explain the need for education, the client's belief in personal benefits is more motivating.
B. The client's belief that his needs will be met through education.
The belief that their needs will be met through education fosters motivation.
C. The nurse's empathy about the client having to self-inject.
Empathy from the nurse can enhance the learning experience but might not solely motivate the client.
D. The client seeking family approval by agreeing to a teaching plan.
Seeking family approval is an external motivator, but personal belief in the benefits of education is more intrinsic.
Full Explanation
A. While it's important for the nurse to explain the need for education, the client's belief in personal benefits is more motivating.
B. The belief that their needs will be met through education fosters motivation.
C. Empathy from the nurse can enhance the learning experience but might not solely motivate the client.
D. Seeking family approval is an external motivator, but personal belief in the benefits of education is more intrinsic.
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.)
A. "I will use the grab bars when getting in and out of the bathtub."
Using grab bars enhances safety while bathing.
B. "I need to have a fire escape plan with my family."
Having a fire escape plan contributes to home safety.
C. "I need to check my medication expiration dates."
Checking medication expiration dates ensures safe and effective use.
D. "I need to set my hot water heater to 140 degrees Fahrenheit."
Setting the water heater to 140 degrees Fahrenheit may pose a scalding risk.
E. "I will apply tape over frayed areas of electrical cords."
Applying tape to electrical cords is not a safe practice and does not indicate an understanding of safety precautions.
Full Explanation
A. Using grab bars enhances safety while bathing.
B. Having a fire escape plan contributes to home safety.
C. Checking medication expiration dates ensures safe and effective use.
D. Setting the water heater to 140 degrees Fahrenheit may pose a scalding risk.
E. Applying tape to electrical cords is not a safe practice and does not indicate an understanding of safety precautions.
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, "I want to die now that my partner is gone." Which of the following responses should the nurse make?
A. "You should discuss these feelings with your provider."
Advising to discuss with the provider doesn't address the immediate concern of potential harm.
B. "Have you thought about harming yourself?"
Asking about thoughts of self-harm assesses the client's immediate safety.
C. "Why did you stop taking your medication?"
Inquiring about medication discontinuation is important but not as urgent as addressing suicidal ideation.
D. "Tell me more about your partner."
While understanding the relationship is important, it's not the priority when a client expresses suicidal thoughts.
Full Explanation
A. Advising to discuss with the provider doesn't address the immediate concern of potential harm.
B. Asking about thoughts of self-harm assesses the client's immediate safety.
C. Inquiring about medication discontinuation is important but not as urgent as addressing suicidal ideation.
D. While understanding the relationship is important, it's not the priority when a client expresses suicidal thoughts.