a nurse is developing a plan of care for an older adult who is at risk for falls which of the following actions should the nurse include
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Nursing Elites

ATI RN

RN ATI Capstone Proctored Comprehensive Assessment 2019 B with NGN

1. A nurse is developing a plan of care for an older adult who is at risk for falls. Which of the following actions should the nurse include?

Correct answer: A

Rationale: The correct action for the nurse to include in the plan of care for an older adult at risk for falls is to lock beds and wheelchairs when not in use. This measure is crucial for preventing falls and ensuring patient safety in healthcare settings. Administering sedatives at bedtime (Choice B) is not recommended as it does not address the underlying risk factors for falls and may increase the risk of injury. Providing information about home safety checks (Choice C) is important for fall prevention in the home environment but is not directly related to healthcare settings. Teaching balance and strengthening exercises (Choice D) is beneficial for fall prevention but may not be suitable for all older adults at risk for falls, especially in acute care settings.

2. What is a recommended nursing action for a client who experiences short-term memory loss after Electroconvulsive Therapy (ECT)?

Correct answer: B

Rationale: The correct nursing action for a client experiencing short-term memory loss after ECT is to offer frequent orientation and reassurance. This helps the client feel supported and aids in memory retention. Providing cognitive-behavioral therapy (Choice A) may be beneficial for other conditions but is not the primary intervention for memory loss post-ECT. Administering a sedative (Choice C) is not recommended as it may further affect memory recall. Referring the client to a neurologist (Choice D) for further evaluation is not the initial action needed; offering support and orientation should be the first approach to manage memory issues post-ECT.

3. A client just had a flexible bronchoscopy. Which of the following nursing actions is appropriate?

Correct answer: B

Rationale: After a flexible bronchoscopy, it is essential to withhold food and liquids until the client's gag reflex returns. This precaution helps prevent aspiration, as the gag reflex protects the airway from foreign material. Irrigating the client's throat every 4 hours (Choice A) is unnecessary and may increase the risk of aspiration. Suctioning the client's oropharynx frequently (Choice C) can cause trauma and is not indicated unless there is a specific medical reason for it. Having the client refrain from talking for 24 hours (Choice D) is not necessary after a flexible bronchoscopy.

4. A nurse suspects a colleague of diverting narcotics. What is the nurse's first course of action?

Correct answer: B

Rationale: The correct first course of action for a nurse suspecting a colleague of diverting narcotics is to report the suspicion to the nurse manager. Confronting the colleague directly may not be safe and could compromise the investigation. Ignoring the situation is not appropriate as it can pose risks to patient safety. Keeping a record of the colleague's actions is not the primary action to take when drug diversion is suspected; reporting to the nurse manager is crucial for proper investigation and ensuring patient safety.

5. A nurse is caring for a client who has not voided for 8 hours following the removal of an indwelling urinary catheter. Which of the following actions should the nurse take first?

Correct answer: D

Rationale: Performing a bladder scan is the first step to assess bladder retention before any further interventions.

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