A nurse at a longterm facility is planning a fall

Extract:

Question 1 of 5

A nurse at a long-term facility is planning a fall prevention program for the residents. Which of the following interventions should the nurse include?

A. Institute rounds every 2 hr. during the day to offer toileting. B. Keep four side rails up on the beds at night C. Apply vest restraints on the residents who are confused D. Accompany residents older than 85 years of age during ambulation

Correct Answer: A

Rationale: Regular toileting rounds reduce fall risk by addressing bathroom needs. Four side rails risk entrapment, restraints increase injury risk, and age-based ambulation is overly restrictive.

Question 2 of 5

A nurse enters the hallway and discovers a visitor looking at a client's medical information on a computer. Which of the following actions should the nurse take first?

A. Close the documentation program on the computer B. Find out which staff member left the documentation program on the screen C. Tell the charge nurse that the visitor viewed a client's protected health information D. Inform the visitor that client records are confidential

Correct Answer: A

Rationale: Closing the program prevents further unauthorized access immediately. Investigating staff , reporting to the charge nurse , or informing the visitor follow after securing the system.

Question 3 of 5

A nurse is teaching a newly licensed nurse about client confidentiality. The nurse should include which of the following examples represents a violation of client confidentiality?

A. Calling the pharmacy with a prescription for the client's partner to pick up B. Informing housekeeping staff that the client is in the dialysis unit C. Reporting a client's disposition to the referring provider D. Providing a copy of the client's medical record to the transporting paramedic

Correct Answer: B

Rationale: Informing housekeeping about a client's location breaches confidentiality, as it's unnecessary. Pharmacy calls , provider reports , and paramedic records are part of care coordination.

Question 4 of 5

A nurse in a prenatal clinic is caring for a group of clients. Which of the following clients should the nurse recommend for an interdisciplinary care conference?

A. A client who is 37 weeks gestation and has an L/S ratio of 2:1 B. A client who is 28 weeks gestation and has a negative Coombs's titer C. A client who is at 39 weeks gestation and has a negative contraction stress test D. A client who is at 35 weeks gestation and has a biophysical profile of 6

Correct Answer: D

Rationale: A biophysical profile of 6 indicates potential fetal compromise, necessitating team discussion. Normal L/S ratio , negative Coombs , and negative stress test don't require immediate conferences.

Question 5 of 5

A nurse working on a quality improvement team that is assessing an increase in client falls at the facility. After problem identification, which of the following actions should the nurse plan to take first as part of the quality improvement process?

A. Review current literature regarding client falls B. Implement a fall prevention plan C. Identify clients who are at risk for falls D. Notify staff of the increased fall rate

Correct Answer: C

Rationale: Identifying at-risk clients targets interventions effectively. Literature review , plan implementation , and staff notification follow risk assessment.

Nurselytic

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ATI Leadership Level 3 Questions

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