A nurse caring for patients in a long-term care facility knows that there are factors that place certain patients at a higher risk for falls.
Which patients would the nurse consider to be in this category? Select all that apply.
A patient who experiences postural hypotension.
A patient who is experiencing nausea from chemotherapy.
A patient who has already fallen twice.
A patient who is older than 50 years old.
A patient who is transferred to long-term care.
Correct Answer : A,C,E
Choice A rationale
A patient who experiences postural hypotension is at a higher risk for falls. Postural hypotension, or a sudden drop in blood pressure upon standing, can cause dizziness and increase the likelihood of falling. This condition is common in older adults and those with certain medical conditions.
Choice B rationale
A patient who is experiencing nausea from chemotherapy is not necessarily at a higher risk for falls. While nausea can cause discomfort and weakness, it does not directly contribute to an increased risk of falling. Other factors, such as medication side effects or balance issues, are more significant in fall risk assessment.
Choice C rationale
A patient who has already fallen twice is at a higher risk for future falls. A history of falls is a strong predictor of subsequent falls, as it may indicate underlying issues such as balance problems, muscle weakness, or environmental hazards.
Choice D rationale
A patient who is older than 50 years old is not automatically at a higher risk for falls. While age is a factor, the risk significantly increases for individuals over 65 years old. Other factors, such as medical conditions and medication use, play a more critical role in fall risk assessment.
Choice E rationale
A patient who is transferred to long-term care is at a higher risk for falls. The transition to a new environment can be disorienting, and patients may be unfamiliar with their surroundings. Additionally, long-term care patients often have multiple health issues that contribute to an increased fall risk.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale
Implementing the order immediately without verifying is unsafe and can lead to errors. Nurses must ensure clarity and accuracy before carrying out any orders.
Choice B rationale
Writing down the order and reading it back to the physician is the correct action. This ensures that the order is understood correctly and reduces the risk of errors.
Choice C rationale
Asking the physician to repeat the order multiple times is unnecessary and can be seen as unprofessional. Writing down and reading back the order is a more effective method.
Choice D rationale
Ignoring the order if it seems unclear is not appropriate. Nurses have a responsibility to clarify any unclear orders to ensure patient safety.
Correct Answer is B
Explanation
Choice A rationale
Reporting unusual lung sounds requires assessment skills that are beyond the scope of practice for an unlicensed assistive personnel (UAP). UAPs are not trained to interpret or evaluate clinical data, which is essential for identifying unusual lung sounds. This task should be performed by a licensed nurse who can accurately assess and respond to the findings.
Choice B rationale
Providing assistance with morning care is within the scope of practice for UAPs. This task involves helping the patient with activities of daily living such as bathing, dressing, and grooming, which do not require clinical judgment or assessment skills. It is a routine task that UAPs are trained to perform safely and effectively.
Choice C rationale
Teaching the patient about a heart-healthy diet involves providing education and requires a thorough understanding of the patient’s medical condition and dietary needs. This task should be performed by a licensed nurse or dietitian who has the knowledge and skills to provide accurate and comprehensive education.
Choice D rationale
Checking the client’s blood pressure medication involves administering medication, which is outside the scope of practice for UAPs. Medication administration requires knowledge of pharmacology, the ability to assess the patient’s response to the medication, and the ability to recognize and respond to potential side effects. This task should be performed by a licensed nurse.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.