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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.

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Correct Answer is ["A","B","C","E"]

Explanation

A. ABG results: pH 7.32 (acidosis), HCO₃⁻ 18 mEq/L (low), PaO₂ 68 mm Hg, SaO₂ 90%. Indicates metabolic acidosis with hypoxemia. This is a significant abnormality needing prompt attention.

B. Amylase results: Elevated amylase is a hallmark of acute pancreatitis and confirms the suspected diagnosis.

C. Temperature: Fever with pancreatitis can signal systemic inflammatory response or infection, requires provider notification.

D. Hematocrit level: 42%, within the normal range (female 38–47%, male 42–52%).

E. Pain report: Severe abdominal pain 8/10, persistent >24 hours. Pancreatitis pain requires provider management (often opioids, supportive care).

F. Glucose level: 108 mg/dL is within normal limits (70–110). It is not concerning at this time.

A. "This medication can cause back pain." B. "Avoid taking this medication with milk products." C. "Use an electric razor when shaving while taking this medication." D. "Avoid prolonged exposure to sunlight while taking this medication."

Correct Answer is C

Explanation

Rationale:

A. "This medication can cause back pain.": Back pain is not a common or expected adverse effect of warfarin. Teaching should focus on bleeding risks and precautions rather than unrelated symptoms.

B. "Avoid taking this medication with milk products.": Milk does not significantly affect warfarin absorption. The main dietary consideration is maintaining consistent vitamin K intake, as large fluctuations can alter anticoagulation.

C. "Use an electric razor when shaving while taking this medication.": Warfarin increases the risk of bleeding and bruising. Using an electric razor reduces the chance of cuts, promoting safety during routine grooming.

D. "Avoid prolonged exposure to sunlight while taking this medication.": Sun exposure is not contraindicated with warfarin; there is no significant interaction between warfarin and UV light.

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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 in an emergency department is caring for a client. Exhibits Select the 4 findings the nurse should report to the provider.

Correct Answer is ["A","B","C","E"]

Explanation

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Correct Answer is C

Explanation

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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.