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.

Answer and Explanation

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.

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Correct Answer is B

Explanation

Choice A rationale
Asking the client to demonstrate walking with the crutches is part of the evaluation step, not the teaching plan. It assesses the client’s understanding and ability to perform the skill.
Choice B rationale
Assessing the client’s readiness to learn is a crucial step in the teaching plan. It ensures that the client is mentally and emotionally prepared to absorb and apply the information being taught.
Choice C rationale
Developing short-term goals for the client is part of the planning process, but it is not the initial step in the teaching plan. The nurse must first assess the client’s readiness to learn.
Choice D rationale
Showing the client a video of proper crutch walking is a teaching strategy, but it is not the first step in the teaching plan. The nurse must first assess the client’s readiness to learn.

A. Calculating intake and output for the unit. B. Inserting an NGT for a client who is unable to eat. C. Reinforcing teaching with a patient who is learning to walk with a quad cane. D. An unstable client complaining of feeling faint.

Correct Answer is D

Explanation

Choice A rationale
Calculating intake and output for the unit is a task that can be delegated to an LVN or UAP. It does not require the advanced clinical judgment and skills of an RN.
Choice B rationale
Inserting an NGT (nasogastric tube) for a client who is unable to eat is a task that can be performed by an LVN under the supervision of an RN. While it requires skill, it does not necessarily require the advanced clinical judgment of an RN.
Choice C rationale
Reinforcing teaching with a patient who is learning to walk with a quad cane can be done by an LVN or UAP. This task involves providing support and encouragement, but it does not require the advanced clinical judgment of an RN.
Choice D rationale
An unstable client complaining of feeling faint requires the advanced clinical judgment and skills of an RN. The RN is best equipped to assess the client’s condition, identify potential causes of instability, and implement appropriate interventions to stabilize the client.

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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.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is preparing a teaching plan for a client who is learning crutch walking. The nurse should identify the following in the teaching plan.

Correct Answer is B

Explanation

A nurse on a medical-surgical unit has received a report on four clients. There is an LVN, RN, and UAP working. Which of the following clients would be best to assign to the RN?

Correct Answer is D

Explanation

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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.