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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 D

Explanation

A. Patient-centered care: This competency focuses on respecting client preferences, values, and needs while involving them in care decisions. Completing an incident report does not directly address individualized client care.

B. Evidence-based practice: Evidence-based practice involves integrating the best current research evidence with clinical expertise and patient values. Documenting an incident report is not based on reviewing or applying research evidence.

C. Informatics: Informatics involves using information technology to communicate, manage knowledge, and support decision-making. While an incident report may use electronic systems, the primary purpose is not focused on informatics competency.

D. Quality improvement: Completing an incident report identifies errors, near misses, or adverse events, which helps the healthcare team analyze processes and implement changes to improve patient safety. This reflects the quality improvement competency by contributing to safer care systems.

A. Provide a tracheostomy tray at the bedside. B. Place the client in supine position. C. Place a plastic tongue depressor at the client's bedside. D. Insert an IV saline lock.

Correct Answer is D

Explanation

Rationale:

A. Provide a tracheostomy tray at the bedside: A tracheostomy tray is not routinely required for seizure precautions, as airway obstruction in seizures is usually managed through positioning and suctioning.

B. Place the client in supine position: The supine position can increase the risk of airway obstruction and aspiration after a seizure. A side-lying position is preferred to help maintain an open airway and promote drainage of secretions.

C. Place a plastic tongue depressor at the client's bedside: Placing any object in a client’s mouth during or after a seizure can cause injury to the teeth, gums, or airway. Modern seizure precautions avoid using tongue blades or depressors entirely.

D. Insert an IV saline lock: Having IV access readily available allows rapid administration of emergency medications such as benzodiazepines if the client experiences another seizure. This intervention supports prompt treatment and stabilization.

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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 is completing an incident report after a client fall. Which of the following competencies of Quality and Safety Education for Nurses is the nurse demonstrating?

Correct Answer is D

Explanation

A nurse is implementing seizure precautions for a client who has had a tonic-clonic seizure. Which of the following interventions should the nurse include in the plan of care?

Correct Answer is D

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.