A nurse is assessing an older adult client’s risk for falls.
Which assessments should the nurse use to identify the client’s safety needs? (Select all that apply)

Pupil clarity

Appearance of gait

Visual fields

Visual acuity

Answer and Explanation

Correct Answer : B,C,D

Choice A rationale

Pupil clarity is not typically used to assess an older adult client’s risk for falls. It is more relevant in neurological assessments.

Choice B rationale

The appearance of gait is a crucial factor in assessing an older adult client’s risk for falls. Abnormalities in gait can increase the risk of falls.

Choice C rationale

Visual fields are important in assessing an older adult client’s risk for falls. Impaired visual fields can increase the risk of falls.

Choice D rationale

Visual acuity is important in assessing an older adult client’s risk for falls. Poor visual acuity can increase the risk of falls.

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Correct Answer is C

Explanation

Choice A rationale

A cup of soup is typically 240 mL, so 2 cups would be 480 mL, which is more than 120 mL1.

Choice B rationale

A quart is a unit of volume equal to 946 mL, which is significantly more than 120 mL1.

Choice C rationale

8 oz of ice chips is approximately equivalent to 120 mL2. This is because when ice melts, it reduces in volume by about half, so 8 oz of ice chips would melt to about 4 oz of water, which is approximately 120 mL2.

Choice D rationale

6 oz is approximately 177 mL, which is more than 120 mL2.

A. The route of administration B. The dosage of the medication C. The frequency of administration D. The name of the medication .

Correct Answer is B

Explanation

Choice A rationale

The route of administration, “by mouth”, is clearly stated in the prescription. Therefore, there is no need to confirm this with the healthcare provider.

Choice B rationale

The dosage of the medication, “0.25”, is not specified in terms of units (e.g., milligrams, micrograms). This could lead to errors in medication administration. Therefore, the nurse should confirm the dosage of the medication with the healthcare provider.

Choice C rationale

The frequency of administration, “daily”, is clearly stated in the prescription. Therefore, there is no need to confirm this with the healthcare provider.

Choice D rationale

The name of the medication, “digoxin”, is clearly stated in the prescription. Therefore, there is no need to confirm this with the healthcare provider.

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A nurse is assessing an older adult client’s risk for falls.Which assessments should the nurse use to identify the client’s safety needs? (Select all that apply)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is documenting a client’s fluid intake over the past 8 hours. Which of the following items should be recorded as 120 mL of fluid in the client’s intake and output record?

Correct Answer is C

Explanation

A nurse is examining a patient’s medication prescription which states, “digoxin 0.25 by mouth daily.”. Which component of the prescription should the nurse confirm with the healthcare provider?

Correct Answer is B

Explanation

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A nurse is assessing an older adult client’s risk for falls.
Which assessments should the nurse use to identify the client’s safety needs? (Select all that apply)