A home health nurse is performing a fall risk assessment for an older adult client. Which of the following findings should the nurse identify as a potential fall risk in the home?

The client has electrical wires secured to baseboards.

The client wears rubber-sole shoes.

The client's visual acuity is 20/40.

The client takes an antihypertensive medication.

Answer and Explanation

The Correct Answer is D

A. Securing electrical wires reduces tripping hazards and promotes safety.

B. Rubber-sole shoes provide better traction and reduce the risk of slips and falls.

C. Reduced visual acuity increases the risk of falls but not as much as taking antihypertensives do.

D. Taking an antihypertensive medication can be a potential fall risk, because it can cause hypotension and dizziness.

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Correct Answer is B

Explanation

A. Cooling the solution is not necessary and may cause discomfort to the client.

B. Using a syringe with a catheter allows for precise and controlled irrigation of the wound, helping to remove debris and promote healing.
C. Wearing a fresh pair of gloves for irrigation helps prevent contamination and reduces the risk of infection.
D. Administering analgesia may help manage pain during the procedure, but it is not directly related to the technique of wound irrigation.

A. Hold the dropper 3 cm (1.2 in) away from the client's eye. B. Massage the client's eyelids for 20 seconds after instillation. C. Wait 5 min between the administration of each medication. D. Ask the client to close their eyes tightly after instilling each medication.

Correct Answer is C

Explanation

A. The dropper should be held about 1 cm (0.4 in) away from the eye to avoid touching or injuring the eye or contaminating the dropper tip.
B. Massaging the eyelids after instillation is not a standard practice and may cause discomfort or injury to the eye.
C. Administering multiple ophthalmic medications requires a sufficient interval between doses to prevent interactions and ensure effectiveness.
D. Asking the client to close their eyes tightly may squeeze out some of the medication or increase intraocular pressure.

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A home health nurse is performing a fall risk assessment for an older adult client. Which of the following findings should the nurse identify as a potential fall risk in the home?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A charge nurse is observing a staff nurse performing a wound irrigation for a client who has a pressure injury. Which of the following actions by the staff nurse indicates an understanding of the procedure?

Correct Answer is B

Explanation

A nurse is administering multiple types of ophthalmic drops to a client. Which of the following actions should the nurse take?

Correct Answer is C

Explanation

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