A nurse is assessing a client to determine their fall risk. Which of the following findings should alert the nurse that the client is at risk for falls?

1+ pedal edema

Bruises on the lower extremities

Impaired vision

Coarse rhonchi auscultated over the trachea

Answer and Explanation

The Correct Answer is C

A. 1+ pedal edema. Mild pedal edema is typically not associated with instability or falls, unless it progresses to severe swelling that affects mobility or balance. It is a sign of fluid retention but not a direct fall risk indicator on its own.
B. Bruises on the lower extremities. Bruising can be a sign of previous falls or trauma, but it is not itself a cause or indicator of fall risk. While it may prompt further investigation, it does not confirm fall risk independently.
C. Impaired vision. Visual impairment is a significant risk factor for falls because it affects depth perception, ability to detect hazards, and overall spatial awareness. Clients with impaired vision are more likely to trip, misjudge steps, or bump into obstacles.
D. Coarse rhonchi auscultated over the trachea. Coarse rhonchi are respiratory findings typically related to mucus in the airways and do not directly contribute to fall risk unless accompanied by severe respiratory distress or fatigue.

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Free Nursing Study Resources

Correct Answer is B

Explanation

A. Open the outermost flap of the sterile kit toward the body. The outermost flap should always be opened away from the body first to prevent contamination of the sterile field by leaning over it. This helps maintain sterility by minimizing the risk of contact.
B. Place the cap from the solution sterile side up on a clean surface. Placing the cap sterile side up prevents the sterile inner surface from touching the contaminated surface and helps maintain aseptic technique during solution use.
C. Place the sterile dressing within 1.25 cm (0.5 in) of the edge of the sterile field. The outer 2.5 cm (1 inch) border of a sterile field is considered contaminated. Placing items too close to the edge increases the risk of contamination and compromises the field's sterility.
D. Set up the sterile field 5 cm (2 in) below waist level. Any sterile item held or placed below waist level is considered contaminated. The sterile field must always be maintained above waist level to preserve asepsis.

A. "I will use a communication board to assess the client's needs." B. “I will collaborate with a speech therapist about the client's plan of care." C. "I will use indirect lighting in the client's room." D. “I will use a loud tone of voice when speaking with the client.”

Correct Answer is C

Explanation

A. Using a communication board is appropriate for clients with speech or language impairments, not visual impairment.
B. Collaborating with a speech therapist is indicated for speech or communication disorders, not vision loss.
C. Using indirect lighting in the room is correct because it reduces glare and enhances visibility for clients with visual impairment, improving safety and comfort.
D. Speaking in a loud tone of voice is unnecessary unless the client also has a hearing impairment; visual impairment does not affect hearing.

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A nurse is assessing a client to determine their fall risk. Which of the following findings should alert the nurse that the client is at risk for falls?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is B

Explanation

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Correct Answer is C

Explanation

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