Test bank nursing 1-5 chapters Questions and answers Distinction Guranteed

Test bank nursing 1-5 chapters 1) The nurse is caring for a client who is prone to falls. Which nursing diagnosis would be most appropriate for this client? A) Risk for Injury B) Risk for Suffocation C) Deficient Knowledge D) Risk for Disuse Syndrome - ANS Answer: A Explanation: A) Risk for Injury is a state in which the individual is at risk as a result of environmental conditions such as a fall. Deficient Knowledge deals with injury prevention. Risk for Disuse Syndrome is a deterioration of a body system as the result of prescribed or unavoidable musculoskeletal inactivity. Risk for Suffocation occurs when inadequate air is available for inhalation. 2) A nurse manager is assessing the hospital environment in order to decrease the risk for client falls. Which is the best intervention to decrease the risk of client falls? A) Keep the call button within reach at all times. B) Read label directions. C) Keep electrical cords under the bed. D) Clean the environment of clutter. - ANS Answer: D Explanation: A) Keeping the environment tidy and free of clutter will go a long way in preventing falls. The call button should always be within reach of the client, but is not the best way to prevent falls. Electrical cords should be used only if necessary, and the maintenance department can help if any of them present a hazard. Reading label directions will prevent the wrong use of substances given to the client but would not directly prevent falls. 3) A client in the intensive care unit is combative and pulling at the endotracheal tube, which must remain in place. After applying soft hand restraints to protect the client's airway, which action should the nurse take next? A) Notify the physician. B) Notify the family of the need for restraints. C) Reassess the need for the restraints in 8 hours. D) Document the application of restraints in the chart. - ANS Answer: A Explanation: A) According to the law, the physician must see the client and write an order within 1 hour of application of restraints. The nurse would apply the restraints to protect the airway and then immediately notify the physician. The nurse would notify the family if present, but that is not the legal priority. The nurse would document the use of restraints as soon as possible after notifying the physician. Most agencies require reassessment of need every 1-2 hours. 4) A client asks the nurse if the staff members make many mistakes because there are so many posters and signs about safety on the walls. What should the nurse respond to this client? A) "We want the public to know we are trying to be safe." B) "Clinic staff members require frequent reminders about client safety." C) "National safety goals focus on the individual making the error." D) "National safety goals seek prevention of injury." - ANS Answer: D Explanation: A) National Patient Safety Goals are focused on solutions to safety issues and prevention of further injuries. Instead of focusing on the individual who made the error, the goals focus on finding ways to prevent that error from happening again. The staff members should not need to be reminded about safety, as safety should be the culture of health care. Healthcare agencies want the public to know about their safety promotions, but that is not the goal of the program.