Try Naxlex NCLEX-RN (Free-Trial)

A nurse is caring for an older adult client newly admitted to the medical unit.

Exhibits

Click to highlight the pieces of information that indicate the client is at risk for falls. To deselect a piece of information, click on that piece of information again.

Nurses' Notes

1000:

An older adult client admitted following a fall down approximately five steps. Client's partner reports client possibly hit their head and was a little disoriented for a minute or two. Client states, "I feel fine. I just slipped." Client has a history of falls and orthostatic hypotension per client's partner. Client uses a walker and wears rubber-soled slippers at home. Client ordered new glasses following an eye exam last week but has not received them yet. Partner states they both do exercises that focus on coordination, three times per week.

Vital Signs

1000:

Temperature 37° C (98.6° F)

Heart rate 72/min Respiratory rate 20/min

Blood pressure

Lying: 130/90 mm Hg

Sitting: 128/88 mm Hg

Standing: 98/60 mm Hg

Oxygen saturation 97% on room air

admitted following a fall down approximately five steps

client possibly hit their head and was a little disoriented for a minute or two

history of falls and orthostatic hypotension per client's partner

uses a walker

Client ordered new glasses following an eye exam last week but has not received them yet

Lying: 130/90 mm Hg

Sitting: 128/88 mm Hg

Standing: 98/60 mm Hg

Answer and Explanation

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

The key pieces of information that indicate the client is at risk for falls include:

Admitted following a fall down approximately five steps – Indicates a recent fall history.
Client's partner reports client possibly hit their head and was a little disoriented for a minute or two – Suggests potential confusion or altered mental status.
Client has a history of falls and orthostatic hypotension per client's partner – A significant risk factor for future falls.
Client uses a walker – Indicates mobility impairment.
Client ordered new glasses following an eye exam last week but has not received them yet – Vision impairment increases fall risk.
Blood pressure: Lying: 130/90 mm Hg, Sitting: 128/88 mm Hg, Standing: 98/60 mm Hg – Orthostatic hypotension (drop in BP upon standing) can cause dizziness and falls.

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 B

Explanation

A. "An AP may monitor the peripheral IV insertion site of a client who is receiving replacement fluids." –
Monitoring IV sites requires assessment skills and clinical judgment, which are within the scope of a licensed nurse, not assistive personnel.
B. "An AP may count the respirations of a client who is going to have surgery later the same day." –
Counting respirations is a basic task within the AP’s scope of practice. However, the nurse is responsible for interpreting the findings.
C. "An AP may take orthostatic blood pressure measurements from a client who reports dizziness." –
Measuring orthostatic blood pressure requires critical thinking and assessment of the client’s condition, which falls under the nurse’s responsibilities.
D. "An AP may perform a central line dressing change for a client who is ready for discharge." –
Performing a central line dressing change is a sterile procedure that requires nursing assessment and should be completed by a licensed nurse.

A. Plan to assign a different nurse to the client each shift. B. Start discharge planning on the day of admission. C. Request that the client complete a satisfaction survey at discharge. D. Limit the number of interdisciplinary team members managing the client's care.

Correct Answer is B

Explanation

A. Plan to assign a different nurse to the client each shift. Assigning different nurses each shift disrupts continuity of care. Whenever possible, consistent nursing assignments improve client outcomes.
B. Start discharge planning on the day of admission. Discharge planning should begin upon admission to ensure a smooth transition of care, reduce hospital readmissions, and promote better long-term outcomes.
C. Request that the client complete a satisfaction survey at discharge. While client feedback is valuable, it does not directly contribute to continuity of care during the hospital stay.
D. Limit the number of interdisciplinary team members managing the client's care. Interdisciplinary collaboration (e.g., physicians, nurses, physical therapists, social workers) is crucial in providing comprehensive and continuous care, especially for complex cases.

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

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse on a medical-surgical unit is teaching a newly licensed nurse about tasks to delegate to assistive personnel (AP). Which of the following statements by the newly licensed nurse indicates an understanding of the teaching?

Correct Answer is B

Explanation

A charge nurse on an acute care unit is planning care for a client. Which of the following actions should the nurse take to promote the client's continuity of care?

Correct Answer is B

Explanation

A nurse is inspecting equipment safety in a client's home. The nurse should identify that which of the following findings requires an intervention?

A nurse is caring for an adult client after a fall. Which of the following assessment findings indicates the client may be bleeding internally?

A nurse is assessing a client who is receiving a blood transfusion. The nurse notes lung crackles, hypoxia, and distended neck veins. Which of the following actions should the nurse take? (Select all that apply.)

A nurse is caring for a client who wants to stop receiving treatment for terminal cancer. The client's family asks the nurse if it is possible to continue the treatment without the client's knowledge. Which of the following responses should the nurse make?

A nurse is assessing an older adult client who reports pain. Which of the following should the nurse recognize about the client's perception of pain?

A nurse is teaching a client about fire safety at home. Which of the following information should the nurse include in the teaching?

A nurse is preparing to administer phenobarbital 30 mg PO to a client. Available is phenobarbital 20 mg/5 mL. How many mL should the nurse administer? (Round the answer to the nearest tenth. Use a leading zero if it applies. Do not use a trailing zero.)

44. A nurse is preparing to provide foot care for a client who is ambulatory. Identify the sequence of steps the nurse should follow when performing foot care. (Move the steps into the box on the right, placing them in the order of performance. Use all the steps.)