You note that Unit 64 has had a high turnover rate of staff during the past year. In selecting the appropriate action, it is important that:

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Question 1 of 5

You note that Unit 64 has had a high turnover rate of staff during the past year. In selecting the appropriate action, it is important that:

Correct Answer: C

Rationale: Confidentiality encourages honest reporting of issues like intimidation.

Question 2 of 5

Which of the following should be included in a plan of care for a client receiving total parenteral nutrition (TPN)?

Correct Answer: B

Rationale: Changing TPN solution every 24 hours is essential, per the document, to prevent bacterial overgrowth in the hypertonic solution, ensuring safety. Withholding meds is incorrect; they can coexist. Flushing isn't required pre-TPN, and bed rest isn't mandated by TPN mobility depends on condition. B aligns with infection control standards, reducing sepsis risk, making it a key care plan element.

Question 3 of 5

An 85-year-old male patient has been bedridden for two weeks. Which of the following complaints by the patient indicates to the nurse that he is developing a complication of immobility?

Correct Answer: A

Rationale: Stiffness in the right ankle indicates an immobility complication, per the document, suggesting early contracture or atrophy from disuse. Gum soreness , memory loss , and appetite decrease aren't directly tied to immobility. A signals musculoskeletal decline, a common elderly risk, making it the relevant complaint.

Question 4 of 5

An 86 year-old nursing home resident who has impaired mental status is hospitalized with pneumonic infiltrates in the right lower lobe. When the nurse assists the client with a clear liquid diet, the client begins to cough. What should the nurse do next?

Correct Answer: B

Rationale: Checking the gag reflex is the next step when an 86-year-old with pneumonia coughs on a clear liquid diet. Coughing suggests aspiration risk, common in impaired mental status; a weak gag reflex confirms swallowing issues, necessitating swallowing evaluation. Thickening fluids or solids assumes causation prematurely. IV fluids don't address aspiration. B ensures safety, guiding further interventions, making it the priority action.

Question 5 of 5

A client in a long term care facility complains of pain. The nurse collects data about the client's pain. The first step in pain assessment is for the nurse to

Correct Answer: C

Rationale: Accepting the client's report of pain is the first step in assessment. Pain is subjective; validating it builds trust and ensures accurate data collection, per standards. Coping methods and location/intensity follow. Status is vague. C aligns with pain management principles, prioritizing patient experience, making it the initial action.

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