which nursing intervention is the highest priority for a client at risk for falls in a hospital setting
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Nursing Elites

NCLEX-RN

NCLEX RN Predictor Exam

1. Which nursing intervention is the highest priority for a client at risk for falls in a hospital setting?

Correct answer: D

Rationale: The highest priority nursing intervention for a client at risk for falls in a hospital setting is to place the bed in the lowest position. This action ensures that the client falls the shortest distance, reducing the risk of injury. Keeping all side rails up (Option A) may lead to a fall with injury, as the client might attempt to get over the rail and fall from a higher distance. Reviewing prescribed medications (Option B) is important as certain medications can increase the risk of falling, but it is not the best answer as it is not applicable to all clients. Completing the "get up and go"? test (Option C) can help assess a client's risk for falling but does not directly prevent injury.

2. Many Asians believe in the yin/yang theory, which is rooted in the ancient Chinese philosophy of Tao. Which statement most accurately reflects this philosophy's view of "health"??

Correct answer: C

Rationale: In the yin/yang theory rooted in ancient Chinese philosophy, health is believed to exist when all aspects of a person are in perfect balance. This includes physical, mental, emotional, and spiritual well-being. Choice C accurately reflects this philosophy's view of health. Choices A, B, and D do not capture the essence of the yin/yang theory. Being able to work and produce, being happy and stable, or caring for others and functioning socially, while important, do not encompass the holistic balance emphasized in the yin/yang theory.

3. Which practice will help reduce the risk of a needlestick injury?

Correct answer: C

Rationale: To reduce the risk of a needlestick injury, it is essential to keep a sharps container nearby where it can be easily accessed. This practice ensures quick and safe disposal of needles after use, minimizing the chances of accidental needlesticks. Recapping needles should be avoided as it increases the risk of injuries. Passing needles between workers should also be avoided to prevent accidental needle pricks during handovers. Therefore, the best practice to prevent needlestick injuries is to maintain a sharps container nearby for safe and immediate disposal of needles.

4. What does the medical term 'basophilia' refer to?

Correct answer: B

Rationale: The correct answer is 'An overabundance of a particular white blood cell in the peripheral blood.' Basophilia specifically indicates an increased number of basophils in the peripheral blood. It can be observed in conditions like leukemia and certain allergic reactions. Choice A is incorrect as it describes something unrelated to basophilia. Choice C is incorrect as it suggests a decrease in basophils, which is opposite to the actual meaning of basophilia. Choice D is also incorrect as basophilia does have a defined medical significance.

5. The healthcare professional has collected the following information on a patient: palpated blood pressure"?180 mm Hg; auscultated blood pressure"?170/100 mm Hg; apical pulse"?60 beats per minute; radial pulse"?70 beats per minute. What is the patient's pulse pressure?

Correct answer: B

Rationale: Pulse pressure is the numerical difference between the systolic and diastolic blood pressure readings. In this case, the systolic blood pressure is 170 mm Hg, and the diastolic blood pressure is 100 mm Hg. Therefore, the pulse pressure is calculated as 170 - 100 = 70 mm Hg. Pulse pressure reflects the stroke volume, the amount of blood ejected from the heart with each beat. Choices A, C, and D are incorrect because they do not accurately represent the difference between the systolic and diastolic blood pressure readings provided.

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