A home health nurse is providing teaching to an older adult client who is at risk for falls.
Which of the following statements by the client indicates a need for further teaching?

"I will have my vision checked."

"I will put socks on when I get out of bed."

"I will put a safety bar near my toilet."

"I will put a night-light in the hallway."

Answer and Explanation

The Correct Answer is B

A.   Having vision checked is a positive step to prevent falls by addressing potential visual impairments.
B.   Wearing socks when getting out of bed increases the risk of slipping, indicating a need for further teaching.
C.   Placing a safety bar near the toilet is a preventive measure against falls.
D.   Putting a night-light in the hallway helps improve visibility and reduce the risk of tripping

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Correct Answer is ["1690"]

Explanation

To calculate the 8-hr fluid intake, convert all the measurements to milliliters (mL).

1 oz = 30 mL, so 6 oz of tea = 180 mL, 4 oz of apple juice = 120 mL, 8 oz of water = 240 mL, 3 oz of flavored gelatin = 90 mL, and 6 oz of broth = 180 mL.

Add up all the fluid intake from IV fluids and clear liquids: 880 + 180 + 120 + 240 + 90 + 180 = 1690 mL.

Round the answer to the nearest whole number: 1690 mL.

The nurse should document 1690 mL as the client's 8-hr fluid intake.

A. A client who has diminished vision ambulating in well-lit areas B. A client who received a diuretic 30 min ago C. A client who requires assistance with ambulation D. A client who had a tonic-clonic seizure 2 hr ago

Correct Answer is D

Explanation

A. A client with diminished vision ambulating in well-lit areas may be at risk for falling but is not at the greatest risk among the options provided.
B. A client who received a diuretic 30 min ago may experience orthostatic hypotension, which can increase the risk of falling, but it is not the highest risk.
C. A client who requires assistance with ambulation is generally at a lower risk than a client who has recently experienced a tonic-clonic seizure.
D. A client who had a tonic-clonic seizure 2 hr ago is at the greatest risk for falling due to potential residual weakness, disorientation, or postictal state following the seizure.

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A home health nurse is providing teaching to an older adult client who is at risk for falls. Which of the following statements by the client indicates a need for further teaching?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is ["1690"]

Explanation

A nurse is caring for four clients. Which of the following clients is at the greatest risk for falling?

Correct Answer is D

Explanation

42. A nurse is providing teaching to a client who uses tobacco products. (Move the steps that the nurse should take into the box on the right, placing them in the correct order of performance. All steps must be used.)

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A charge nurse is verifying a client's prescription which another nurse transcribed from a telephone order. Which of the following orders should the nurse recognize as including unaccepted abbreviations when documenting care?

A parish nurse is developing a program of educational sessions to meet the needs of the older adults in the congregation. Which of the following is the best approach to enhance the development of suitable programs?

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A nurse is caring for a client who recently had a below-the-knee amputation. Which of the following client statements demonstrates acceptance of the loss?

A nurse is delegating obtaining the collection of a client's oral temperature to an assistive personnel (AP). The nurse notes in the documentation that the AP obtained the client's axillary temperature. Which of the following rights of delegation should have prevented this situation from occurring?

A home health nurse is providing teaching to an older adult client who is at risk for falls.
Which of the following statements by the client indicates a need for further teaching?