Try Naxlex NCLEX-RN (Free-Trial)

A nurse in a provider's office is caring for a client.

Exhibits
The nurse is performing a fall risk assessment for the client. Select the 3 findings that place the client at risk for a fall.

Prescribed medication

Blood pressure readings

Gait

Reports of home environment

Voiding pattern

Answer and Explanation

Correct Answer : A,B,E

Rationale for correct choices:

Prescribed medication: The client is taking hydrochlorothiazide, a diuretic that can cause dizziness, orthostatic hypotension, and increased nighttime urination. These side effects increase the risk for falls, especially in older adults who may already have mobility limitations.
Blood pressure readings: The client’s blood pressure dropped from sitting 138/84 mm Hg to standing 100/70 mm Hg, indicating orthostatic hypotension. This sudden decrease in blood pressure can cause lightheadedness, dizziness, or fainting, all of which increase the likelihood of falls.
Voiding pattern: The client reports waking 2–3 times per night to void. Nocturia increases fall risk because the client must get up in low-light conditions, potentially while drowsy, making them more susceptible to tripping or losing balance.

Rationale for incorrect choices:

Gait: The client’s gait is steady, and no abnormalities were noted during assessment. While gait disturbances can increase fall risk, in this case, the client’s mobility does not currently contribute to risk.
Reports of home environment: The client has already removed throw rugs and increased lighting, implementing effective fall prevention strategies at home. Therefore, the home environment does not currently place the client at increased risk for falls.

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 C

Explanation

A. "Wear a pair of disposable briefs at bedtime.": Using briefs may provide protection against leakage but does not address the underlying bladder control issue. Bladder retraining focuses on strengthening muscles and establishing voiding schedules.

B. "Limit oral fluid intake to 1,000 milliliters per day.": Restricting fluids can lead to dehydration and urinary tract infections. Adequate hydration is important for bladder health, and fluid restriction is not a recommended strategy for retraining.

C. "Practice pelvic-floor exercises regularly.": Pelvic-floor (Kegel) exercises strengthen the muscles that support bladder control, improve continence, and are a key component of bladder retraining programs. Consistent practice enhances effectiveness over time.

D. "Drink 8 ounces of citrus juice per day.": Citrus juice is not necessary for bladder retraining and may irritate the bladder in some individuals. Dietary recommendations should focus on overall hydration and bladder-friendly fluids rather than specific juices.

A. Wear a gown while providing personal hygiene. B. Place the client in a room with negative airflow, C. Apply a mask when providing care. D. Wipe the stethoscope with alcohol after leaving the client's room.

Correct Answer is A

Explanation

Rationale:

A. Wear a gown while providing personal hygiene: Contact precautions are required for clients with Clostridium difficile to prevent transmission via contaminated surfaces or direct contact. Wearing a gown during personal care protects the nurse’s clothing and skin from spores.

B. Place the client in a room with negative airflow: Negative airflow rooms are required for airborne infections such as tuberculosis or measles. C. difficile is spread via the fecal–oral route and does not require airborne isolation measures.

C. Apply a mask when providing care: Masks are necessary for droplet or airborne pathogens, but C. difficile spores are transmitted through direct or indirect contact, not respiratory droplets, so masks are not routinely required unless there is another indication.

D. Wipe the stethoscope with alcohol after leaving the client's room: C. difficile spores are resistant to alcohol-based disinfectants. Cleaning equipment requires soap and water or a sporicidal disinfectant to effectively remove spores and prevent spread.

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 in a provider's office is caring for a client. Exhibits The nurse is performing a fall risk assessment for the client. Select the 3 findings that place the client at risk for a fall.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is teaching a client about bladder retraining for incontinence. Which of the following instructions should the nurse include in the teaching?

Correct Answer is C

Explanation

A nurse is teaching a group of newly licensed nurses about caring for a client who has a Clostridium difficile infection. Which of the following Instructions should the nurse include in the teaching?

Correct Answer is A

Explanation

A nurse is administering a scheduled medication to a client. The client reports that the medication appears different than what they take at home. Which of the following responses should the nurse make?

A nurse is caring for a client who is 1 hr postpartum. Exhibits For each assessment finding, click to specify if the finding indicates the client's condition has improved or remains unchanged. There must be at least 1 selection in every row. There does not need to be a selection in every column.

A nurse on a medical-surgical unit is delegating tasks to an assistive personnel (AP). Which of the following client care tasks is within the scope of practice for the AP?

A nurse is assessing a client who is at 24 weeks of gestation during a routine prenatal exam. Which of the following findings should the nurse report to the provider?

A nurse is caring for a client who received a transfusion of 250 mL of packed RBCs. The nurse should identify that which of the following findings indicates the client is responding positively to the transfusion?

A charge nurse is teaching a newly licensed nurse about the facility's computerized documentation system. Which of the following information should the nurse include?

A nurse is assessing a client who has preeclampsia and is receiving magnesium sulfate via continuous IV infusion. For which of the following therapeutic effects should the nurse monitor the client?

A nurse in a provider's office is caring for a client.

Exhibits
The nurse is performing a fall risk assessment for the client. Select the 3 findings that place the client at risk for a fall.