N310 Exam 5
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1. a nurse is caring for a client who fell at a nursing home. the client is oriented
to person, place, and time and can follow directions. which of the following
actions should the nurse take to decrease the risk of another fall? (select all
that apply.: -make sure the client's call light is within reach; enables the client to contact the nursing staff to ask
for assistance & prevents the client from falling out of bed while reaching for the call light
-provide the client with nonskid footwear; keeps the client from slipping
-complete a fall-risk assessment; serves as the basis for a plan of care that can then individualize for the client
2. a nurse manager is reviewing with nurses on the unit in the care of a client
who has had a seizure. which of the following statements by a nurse requires
further instruction?: "I will go to the nurses' station for assistance."; during a seizure, stay with the client &
use the call light to summon assistance.
3. a nurse observes smoke coming from under the door of the staff's lounge.
which of the following actions is the nurse's priority?: move clients who are nearby; the
greatest risk to this client is injury from the fire. therefore, the priority intervention is to rescue the clients. protect and
move clients in close proximity to the fire.
4. a nurse is caring for a client who has a history of falls. which of the following
actions is the nurse's priority?: complete a fall-risk assessment; the first action to take using the nursing
process is to assess or collect data from the client. therefore, the priority action is to determine the client's fall risk. this
will work as a guide in implementing appropriate safety measures.
5. a nurse discovers a small paper fire in a trash can in a client's bathroom. the
client has been taken to safety and the alarm has been activated. which of the
following actions should the nurse take?: place wet towels along the base of the door to the client's
room; this contains the fire & the smoke in the room
6. a nurse is providing discharge instructions to a client who has a prescription
for oxygen use at home. which of the following information should the nurse
include? (select all that apply): -nail polish should not be used near a client who is receiving oxygen;
remind the client to not use nail polish or other flammable materials in the home
-a "no smoking" sign should be placed on the front door; have the client place a "no smoking" sign near the front door
and possibly on the client's bedroom door
-a fire extinguisher should be readily available in the home; this is especially important for a client who is receiving
oxygen
, N310 Exam 5
Study online at https://quizlet.com/_htis0q
7. a nurse educator is presenting a module on basic first aid for newly licensed
home health nurses. the client who has heat stroke will have which of the
following?: hypotension; it is a manifestation of heat stroke
8. a nurse educator is conducting a parenting class for new guardians of infants.
which of the following statements made by a participant indicates understand-
ing?: "once my infant starts to push up, i will remove the mobile from over the crib.";the guardian should plan to
remove crib toys (mobiles) from over the bed as soon as the infant begins to push up so the infant is unable to touch
them
9. a home health nurse is discussing the dangers of carbon monoxide poisoning
with a client. which of the following information should the nurse include?: carbon
monoxide binds with hemoglobin in the body; warn the client that carbon monoxide is very dangerous because it binds
with hemoglobin and ultimately reduces the oxygen supplied to the tissues in the body.
10. a home health nurse is discussing the dangers of foodpoisoning with a client.
which of the following information should the nurse include? (select all that
apply): -immunocompromised individuals are at increased risk for complications from food poisoning; warn the
client that very young, very old, immunocompromised & pregnant individuals are at increased risk for complications
from food poisoning
-clients who are at high risk should eat or drink only pasteurized dairy products; include that clients who are at high risk
should follow a low-microbial diet, which includes eating or drinking only pasteruized milk, yogurt, cheese, and other
dairy products
-handling raw & fresh food separately can prevent food poisoning; include interventions to prevent food poisoning
(performing proper hand hygiene, cooking meat & fish to the correct temp, handling raw & fresh food separately to
avoid cross-contamination & refrigerating perishable items).
11. a nurse is caring for a client who has terminal lung cancer. the nurse
observed the client's family assisting with all ADLs. which of the following
rationales for self-care should the nurse communicate to the family?: the client's
sense of loss can be lessened through retaining control of some areas of life; allowing the client as much control as
possible maintains dignity and self-esteem.
12. a nurse is caring for a client who has stage IV lung cancer and is 3 days
postop following a wedge resection. the client stats, "i told myself that i would
go through with the surgery and quit smoking, if i could just live long enough
to attend my child's wedding." based on the kubler-ross model, which stage of
Study online at https://quizlet.com/_htis0q
1. a nurse is caring for a client who fell at a nursing home. the client is oriented
to person, place, and time and can follow directions. which of the following
actions should the nurse take to decrease the risk of another fall? (select all
that apply.: -make sure the client's call light is within reach; enables the client to contact the nursing staff to ask
for assistance & prevents the client from falling out of bed while reaching for the call light
-provide the client with nonskid footwear; keeps the client from slipping
-complete a fall-risk assessment; serves as the basis for a plan of care that can then individualize for the client
2. a nurse manager is reviewing with nurses on the unit in the care of a client
who has had a seizure. which of the following statements by a nurse requires
further instruction?: "I will go to the nurses' station for assistance."; during a seizure, stay with the client &
use the call light to summon assistance.
3. a nurse observes smoke coming from under the door of the staff's lounge.
which of the following actions is the nurse's priority?: move clients who are nearby; the
greatest risk to this client is injury from the fire. therefore, the priority intervention is to rescue the clients. protect and
move clients in close proximity to the fire.
4. a nurse is caring for a client who has a history of falls. which of the following
actions is the nurse's priority?: complete a fall-risk assessment; the first action to take using the nursing
process is to assess or collect data from the client. therefore, the priority action is to determine the client's fall risk. this
will work as a guide in implementing appropriate safety measures.
5. a nurse discovers a small paper fire in a trash can in a client's bathroom. the
client has been taken to safety and the alarm has been activated. which of the
following actions should the nurse take?: place wet towels along the base of the door to the client's
room; this contains the fire & the smoke in the room
6. a nurse is providing discharge instructions to a client who has a prescription
for oxygen use at home. which of the following information should the nurse
include? (select all that apply): -nail polish should not be used near a client who is receiving oxygen;
remind the client to not use nail polish or other flammable materials in the home
-a "no smoking" sign should be placed on the front door; have the client place a "no smoking" sign near the front door
and possibly on the client's bedroom door
-a fire extinguisher should be readily available in the home; this is especially important for a client who is receiving
oxygen
, N310 Exam 5
Study online at https://quizlet.com/_htis0q
7. a nurse educator is presenting a module on basic first aid for newly licensed
home health nurses. the client who has heat stroke will have which of the
following?: hypotension; it is a manifestation of heat stroke
8. a nurse educator is conducting a parenting class for new guardians of infants.
which of the following statements made by a participant indicates understand-
ing?: "once my infant starts to push up, i will remove the mobile from over the crib.";the guardian should plan to
remove crib toys (mobiles) from over the bed as soon as the infant begins to push up so the infant is unable to touch
them
9. a home health nurse is discussing the dangers of carbon monoxide poisoning
with a client. which of the following information should the nurse include?: carbon
monoxide binds with hemoglobin in the body; warn the client that carbon monoxide is very dangerous because it binds
with hemoglobin and ultimately reduces the oxygen supplied to the tissues in the body.
10. a home health nurse is discussing the dangers of foodpoisoning with a client.
which of the following information should the nurse include? (select all that
apply): -immunocompromised individuals are at increased risk for complications from food poisoning; warn the
client that very young, very old, immunocompromised & pregnant individuals are at increased risk for complications
from food poisoning
-clients who are at high risk should eat or drink only pasteurized dairy products; include that clients who are at high risk
should follow a low-microbial diet, which includes eating or drinking only pasteruized milk, yogurt, cheese, and other
dairy products
-handling raw & fresh food separately can prevent food poisoning; include interventions to prevent food poisoning
(performing proper hand hygiene, cooking meat & fish to the correct temp, handling raw & fresh food separately to
avoid cross-contamination & refrigerating perishable items).
11. a nurse is caring for a client who has terminal lung cancer. the nurse
observed the client's family assisting with all ADLs. which of the following
rationales for self-care should the nurse communicate to the family?: the client's
sense of loss can be lessened through retaining control of some areas of life; allowing the client as much control as
possible maintains dignity and self-esteem.
12. a nurse is caring for a client who has stage IV lung cancer and is 3 days
postop following a wedge resection. the client stats, "i told myself that i would
go through with the surgery and quit smoking, if i could just live long enough
to attend my child's wedding." based on the kubler-ross model, which stage of
