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.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is B

Explanation

Choice A rationale
Feeding a stroke client who has difficulty in swallowing is a task that requires careful attention to prevent aspiration and choking. While this task is important, it can be delegated to a trained nursing assistant or a licensed practical nurse (LPN) under the supervision of an RN. The RN should focus on tasks that require higher levels of clinical judgment and expertise.
Choice B rationale
Completing a sterile dressing change to a pressure ulcer is a task that requires the expertise and clinical judgment of an RN. Sterile dressing changes involve maintaining a sterile field, assessing the wound, and applying appropriate dressings. This task is critical for preventing infection and promoting wound healing, making it appropriate for the RN to perform.
Choice C rationale
Reapplying a condom catheter for a client with urinary incontinence is a routine procedure that can be delegated to a trained nursing assistant or an LPN. This task does not require the advanced clinical skills and judgment of an RN, allowing the RN to focus on more complex and critical tasks.
Choice D rationale
Reinforcing teaching with a client who is learning how to administer insulin is an important task, but it can be delegated to an LPN under the supervision of an RN. The RN should prioritize tasks that require higher levels of clinical expertise and judgment, such as sterile dressing changes and complex assessments.

A. A newly admitted client with a seizure disorder. B. A post-op laparotomy client who is waiting for discharge instructions. C. A client who needs assistance with feeding. D. A dehydrated client with an electrolyte imbalance.

Correct Answer is C

Explanation

Choice A rationale
A newly admitted client with a seizure disorder requires close monitoring and assessment, which is beyond the scope of practice for a nursing assistant.
Choice B rationale
A post-op laparotomy client who is waiting for discharge instructions requires specific education and assessment, which is beyond the scope of practice for a nursing assistant.
Choice C rationale
A client who needs assistance with feeding is the correct answer. Assisting with feeding is within the scope of practice for a nursing assistant.
Choice D rationale
A dehydrated client with an electrolyte imbalance requires close monitoring and assessment, which is beyond the scope of practice for a nursing assistant.

View Question and Answer

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

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 on a medical-surgical unit has received a report on four clients. Which of the following clients should the nurse assign to the RN?

Correct Answer is B

Explanation

A nurse is making shift assignments. Which client is appropriate for a nursing assistant?

Correct Answer is C

Explanation

A nurse at the clinic is involved in disease surveillance. What level of prevention is this?

A nurse is caring for a client with cognitive impairment. Which of the following actions should the nurse take to enhance understanding?

What type of research is a nurse conducting if they are using a quasi-experimental design?

A nurse is completing a client’s assessment. Which of the following should the nurse consider as objective data?

The Quality Improvement Team is putting a ‘Fall Risk’ sign on patient doors, providing non-skid socks, conducting frequent rounds of patient rooms, and using color-coded wristbands. Which of the following actions will apply?

What is the primary purpose of a Healthcare Proxy?

The nurse is collaborating with the multidisciplinary team. Which statement about collaboration is correct?

A nurse is teaching a client to administer insulin. The nurse should identify which of the following actions as a priority?

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.