A home health care nurse is conducting a fall risk assessment for a client who has osteoarthritis and lives alone. The nurse should identify that which of the following factors creates a risk for falls?

Large pieces of furniture.

A bedside table next to the bed.

Raised toilet seats.

Throw rugs on hardwood floors.

Answer and Explanation

The Correct Answer is D

Choice A rationale:

Large pieces of furniture do not necessarily create a significant risk for falls unless they are poorly placed or obstructing pathways. While they can potentially cause accidents, the likelihood of tripping over them is generally lower compared to other hazards.

Choice B rationale:

A bedside table next to the bed is not a significant fall risk factor. In fact, having a bedside table can be beneficial for the client, as it provides a convenient surface for placing items that the client might need during the night.

Choice C rationale:

Raised toilet seats, although they may pose a challenge for individuals with mobility issues, are typically installed to aid those with difficulty sitting down or standing up. They are not a primary risk factor for falls, especially when compared to other more hazardous factors.

Choice D rationale:

Throw rugs on hardwood floors are a significant fall risk factor, especially for older adults or individuals with mobility problems. The rugs can easily shift or bunch up, causing someone to trip and fall. Hardwood floors can also become slippery, and the combination of a throw rug on such a surface increases the risk of accidents. The rationale behind this choice is grounded in the potential for tripping and slipping hazards that these throw rugs can introduce, especially in individuals who might already have balance or mobility issues.

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Correct Answer is A

Explanation

Choice A rationale:

This choice reflects the correct technique for maintaining balance and using proper body mechanics when assisting with moving a client up in bed. Shifting weight from the back to the front leg while keeping the feet apart provides a stable base and reduces the risk of injury to the nurse.

Choice B rationale:

Positioning the client's arms at their sides before moving them up in bed is not a necessary step and may not contribute significantly to the process. The primary focus should be on proper body mechanics and the use of assistive devices, such as a draw sheet, to ensure safe patient handling.

Choice C rationale:

Elevating the head of the client's bed 30° is not directly related to the task of moving the client up in bed using a draw sheet. While head elevation might have other clinical indications, it does not impact the technique of assisting with repositioning.

Choice D rationale:

Bending at the waist when grasping the draw sheet is incorrect body mechanics and can lead to strain on the nurse's back. Proper technique involves using the legs to bend and lift while keeping the back straight, reducing the risk of injury.

A. A client who has dehydration with a urine output of 40 mL/hr. B. A client who has cancer and reports pain as 4 on a scale of 0 to 10. C. A client who has asthma and a respiratory rate of 40/min. D. A client who has diabetes mellitus and a fasting blood glucose of 100 mg/dL.

Correct Answer is C

Explanation

Choice A rationale:

Dehydration is a serious condition, and a urine output of 40 mL/hr is indicative of decreased renal perfusion and potential renal failure. However, this situation does not require immediate intervention compared to other choices.

Choice B rationale:

Pain management is important, and a pain score of 4 out of 10 indicates mild to moderate pain. While addressing pain is essential for the client's comfort, it is not an immediate priority compared to the situation presented in another choice.

Choice C rationale:

(Correct Choice) A respiratory rate of 40 breaths per minute in a client with asthma indicates severe respiratory distress. This client is at risk of respiratory failure and requires immediate assessment and intervention.

Choice D rationale:

A fasting blood glucose of 100 mg/dL in a client with diabetes mellitus is within a normal range and does not require immediate attention when compared to the urgent situation in another choice.

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A home health care nurse is conducting a fall risk assessment for a client who has osteoarthritis and lives alone. The nurse should identify that which of the following factors creates a risk for falls?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assisting a coworker with moving a client up in bed using a draw sheet. Which of the following actions should the nurse take?

Correct Answer is A

Explanation

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Correct Answer is C

Explanation

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