ATI Fundies practice test A help

A nurse is assessing an older client's risk for falls. Which of the following assessments should the nurse use to identify the client's safety needs?1. Lacrimal Apparatus2. Pupil clarity3. Appearance on bulbar conjuctivae4. Visual fields5. Visual acuity

*Pupil clarity (cloudy pupils indicate cataracts, which can increase risk of falling*Visual fields (Use a finger to test client's peripheral vision by moving it out of range and then back. Visual impairment can increase fall risk*Visual acuity (assess distance, can increase fall risk-Bulbar conjuctivae will not impede client safety

A nurse is evaluating a client's use of a cane. Which action should the nurse identify as as an indication of correct use?

Client holds the cane on the stronger side of the body (to increase support and maintain alignment)

The nurse is admitting a client who has an abdominal wound with a large amount of purulent drainage. Which type of transmission precautions should the nurse initiate?

Contact precautions (Major wound infections require contact precautions, which means the nurse should admit the client to a private room. All caregivers should wear a gown and gloves during direct contact with patient)

A nurse is caring for a client who requires an NG tube for stomach decompression. Which action should the nurse take when inserting the NG tube?

Have the client take sips of water to promote insertion of the NG into the esophagus (prevents passage of tube into trachea)

A nurse is reviewing a client's fluid and electrolyte status. Which finding should the nurse report to the provider?1. BUN 15 mg/dL2. Creatinine 0.8 mg/dL3. Sodium 143 mEq/L4. Potassium 5.4 mEq/L

Potassium 5.4 mEq/L (value is lower than expected reference range and the nurse should report on it. Client is at risk for dysrythmias)

A nurse is using an open irrigation technique to irrigate a client's indwelling urinary catheter. Which action should the nurse take?

Subtract the amount of irrigant used from the client's urinary output (open irrigation requires instilling 30-40 mL of irrigation fluid)

A nurse is caring for a client who has an NG tube and is receiving intermittent feedings through an open system. Which action should the nurse take first?

Tell the client to keep the head of the bed elevated at least 30 degrees (prevent aspiration of enteral formula, keep head of bed elevated to prevent reflux of the formula backward into the esophagus)