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.

Nursing Test Bank

Test Bank #1: RN Pharmacology Exams Test Bank #2: RN Medical-Surgical Exams Test Bank #3: RN Fundamentals Exams Test Bank #4: RN Maternal-Newborn Exams Test Bank #5: RN Anatomy and Physiology Exams Test Bank #6: RN Obstetrics and Pediatrics Exams Test Bank #7: RN Fluid and Electrolytes Exams Test Bank #9: RN Adult Health Test Bank #10: RN Dosage Calculation Test Bank #11: RN Community Health Exams Test Bank #12: RN Psychology Exams Test Bank #13: RN Nursing Care Of Children Test Bank #14: RN Foundations of Nursing Exams

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

Naxlex Comprehensive Predictor Exams

Exam #1: RN Comprehensive predictor 2023 proctored exam Exam #2: Ati rn vati comprehensive predictor proctored exam Exam #3: Ati Rn Comprehensive Predictor Proctored Exam 2023 Exam #4: Rn Comprehensive Predictor 2023 Proctored Exam - St. Joseph Exam #5: RN Comprehensive Predictor Proctored Exam (National U CA San Diego) Exam #6: Ati rn comprehensive predictor 2023 retake proctored exam Exam #7: RN Hesi Exit Proctored Exam Exam #8: Hesi RN Exit proctored exam Exam #9: Hesi rn exit proctored exam Exam #10: Hesi Rn compass exit B proctored exam

Free Nursing Study Resources

Correct Answer is ["A","B","C","D","E","F","G","H"]

Explanation

Client reports feeling unwell: This is clinically significant when combined with fever, foul-smelling lochia, and elevated WBCs; it could indicate systemic infection such as endometritis.
Fundus boggy but firms with massage: Indicates uterine atony, a risk factor for postpartum hemorrhage. Even if it responds to massage, repeated bogginess suggests the need for uterotonic medications and close monitoring.
Foul-smelling, dark brown lochia: These findings are highly suggestive of uterine infection (endometritis), especially when paired with uterine tenderness, fever, and elevated WBCs.
WBC count 33,000/mm³: Severely elevated — well above normal postpartum leukocytosis (typically up to 20,000/mm³). A level of 33,000 strongly suggests an ongoing infectious process.
Temperature 38.2°C (100.8°F): Slightly elevated, and while low-grade fever is common postpartum, when associated with uterine tenderness and abnormal lochia, it raises concern for infection and should be monitored and managed appropriately.
Lung sounds diminished in the bases: Could be due to post-surgical hypoventilation, immobility, or atelectasis. Should prompt encouragement of deep breathing, incentive spirometry, and ambulation.
No bowel movement since birth, hypoactive bowel sounds: This is a common post-cesarean finding due to anesthesia and immobility, but it still indicates delayed return of GI function and should be monitored for signs of ileus.

A. Request an interpreter of a different sex from the client. B. Request a family member or friend to interpret information for the client. C. Direct attention toward the interpreter when speaking to the client. D. Review the facility policy about the use of an interpreter

Correct Answer is D

Explanation

A. Request an interpreter of a different sex from the client. The interpreter's sex should be based on the client’s cultural preferences, not assumed by the nurse. This decision should be made to promote comfort and cultural sensitivity.
B. Request a family member or friend to interpret information for the client. This is not recommended, especially for medical discussions, as it may lead to misinterpretation, breaches of confidentiality, and biased communication.
C. Direct attention toward the interpreter when speaking to the client. The nurse should speak directly to the client, not the interpreter, to maintain a therapeutic relationship and respect for the client.
D. Review the facility policy about the use of an interpreter. This is the most appropriate initial action. Each facility typically has specific guidelines and procedures for accessing qualified medical interpreters, which the nurse should follow to ensure accurate and ethical communication.

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 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

Correct Answer is ["A","B","C","D","E","F","G","H"]

Explanation

A nurse is caring for a client who speaks a language different from the nurse. Which of the following actions should the nurse take?

Correct Answer is D

Explanation

A nurse is teaching the parents of a toddler about booster seat safety. Which of the following instructions should the nurse include?

A newly licensed nurse working at an HIV clinic is reviewing the responsibilities of her position at the clinic. Which of the following tasks should the nurse identify as tertiary prevention?

A nurse is caring for a client who is at 34 weeks of gestation and has just had an amniocentesis. Which of the following actions should the nurse plan to take?

A nurse is caring for a client. Exhibits The nurse is assessing the client. Select the 4 findings that require immediate follow-up.

A nurse is obtaining a client's manual blood pressure and is having difficulty auscultating sounds. Which of the following actions should the nurse take?

A nurse is performing a skin assessment on a client who has dark skin. Which of the following locations on the client's body should the nurse observe to assess for cyanosis?

A nurse is teaching the guardian of a newborn about formula feeding. Which of the following instructions should the nurse include?