°10.ID: 8482541849A home health nurse has been called to the home of an older postoperative cardiovascular client by the client’s son. The son tells the nurse, “We’re using a hospital bed here at home, but my mother has fallen out of bed three times.” Which observation by the nurse reflects an increased risk of this client’s falling out of bed? The client’s bed is in a low position.The client is oriented to person, place, and time.The caregiver uses the overbed table for feedings.The caregiver leaves both siderails down while the client is in bed. Correct°Rationale: Leaving the siderails of older client’s bed down may increase the client’s risk of falling. The aging process also increases this client’s potential for falls; therefore, evaluating the safety of the environment is a necessity. Keeping the client’s bed in a low position,orientating the client to the environment, and using the overbed table for feedings are all ways to help ensure the client’s safety.°Test-Taking Strategy: Use the process of elimination, focusing on the subject, a observation of an unsafe practice. Noting that the question indicates that the bed is in the low position and that the client is oriented will assist you in eliminating these options. To select from the remaining options, choose the one that identifies an unsafe practice. Review the causes of falls in an older client if you had difficulty with this question. ° Reference: Perry, A., & Potter, P. (2010). Clinical nursing skills & techniques (7th
ed., p. 329). St. Louis: Mosby. ° Cognitive Ability: Evaluating ° Client Needs: Safe and Effective Care Environment ° Integrated Process: Nursing Process/Assessment ° Content Area: Safety ° Giddens Concepts: Client Education, Safety ° HESI Concepts: Safety, Teaching and Learning/Client Education Awarded 1.0 points out of 1.0 possible points. ° 11.ID: 8482539865A community health nurse is providing information to local residents about the transmission of anthrax. Through which body systems does the nurse tell the residents that anthrax can be contracted? Select all that apply. ° Test-Taking Strategy: Specific knowledge of the routes of infection with B. anthracis is needed to answer this question. Remember that anthrax can be contracted through the gastrointestinal system, skin, or lungs. Review content on anthrax and its modes of transmission if you had difficulty with this question. ° Reference: McEwen, M., & Pullis, B. (2009). Community-based nursing: An introduction (3rd ed., p. 410). Philadelphia: Saunders. ° Cognitive Ability: Understanding ° Client Needs: Safe and Effective Care Environment ° Integrated Process: Teaching and Learning ° Content Area: Biological/chemical warfare ° Giddens Concepts: Client Education, Infection ° HESI Concepts: Infection, Teaching and Learning/Client Education Awarded 2.0 points out of 3.0 possible points.
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