RN fundamentals online practice B 2023 Verified Answers

RN fundamentals online practice B 2023 Verified Answers

37. A nurse is caring for a client who has decreased mobility.Which of the fol- lowing action should the nurse take to decrease the clients risk of developing plantar flexion contractures? a. Place a pillow under the client's knees. b. Position a trochanter roll under each of the client's hips. c. Advise the client to wear rubber-soled slippers. d. Apply an ankle-foot orthotic device to the client's feet.: d The nurse should use a device to maintain dorsiflexion, such as an ankle-foot orthotic device or a foot board placed perpendicular to the mattress. 38. The nurse is assessing an older adult clients risk for falls.Which of the following assessmentshould the nurse use to identify the clientsafety needs? (Select all that apply) a. Lacrimal apparatus b. Pupil clarity c. Appearance of bulbar conjunctivae d.Visual fields e.Visual acuity: b, d, e Lacrimal apparatusisincorrect.If clients have an impairment in the ability to produce tears, it should not affect their fall risk.The nurse teststhis by palpating the tear duct at the lower eyelid to see if any tears emerge. Pupil clarity is correct.Cloudy pupils mean that the client has cataracts.This makes vision cloudy and creates halos around lights, which can increase the risk for falls because clients cannot see items in their path clearly. Appearance of bulbar conjunctivae isincorrect.The nurse should examine the bulbar conjunctivae by gently retracting the lower and upper lids to evaluate color and texture and assess for the presence of infection. However, the condition of the conjunctivae will not impede the client's safety. Visual fields is correct.The nurse should use a finger to test the client's peripheral vision by moving the finger out of range and then back into the visual field to determine when the client seesthe finger.Clients who have a visual field impairment are at an increased risk for falls because they might not see objects outside of their central vision and trip over them or bump into them and fall. Visual acuity is correct.The nurse should use a Snellen chart to assess distance vision and a handheld card to assess near vision. Clients who wear eyeglasses should wear them during the assessments.Clients who have impaired visual acuity are at an increased risk for falls because they might notsee objectsin their path and trip over them or bump into them and fall. 39. A nurse is responding to the call and find a client laying on the bathroom floor.Which of the following action should the nurse take first? a. Check the client for injuries. b. Move hazardous objects away from the client. c. Notify the provider. d. Ask the client to describe how they felt prior to the fall.: a The first action the nurse should take when using the nursing process is to assess the client for injuries. 40.Aclientdemonstrates angerwhen thenursedoes not respondwithin 5min of ringing for the nurse.Which of the following is an appropriate response by the nurse? a. "I'm sorry, but another client needed my attention." b. "I could not arrive any sooner.What can I do for you?" c."We had an emergency on the unit and that was a priority,but now I'm here." d. "That must be frustrating for you. How can I help you right now?": d This response is therapeutic because the nurse is acknowledging the client's feel- ings and offering help. 41. A nurse is caring for a client who asked about the purpose of advance directives.Which of the following statements should the nurse make? a. "They allow the court to overrule an adult client's refusal of medical treat- ment." b. "They indicate the form of treatment a client is willing to accept in the event of a serious illness." c. "They permit a client to withhold medical information from health care personnel." d."They allow health care personnel in the emergency department to stabilize a client's condition.": b