A nurse is caring for four clients. Which of the following clients is at the greatest risk for falling?

A client who has diminished vision ambulating in well-lit areas

A client who received a diuretic 30 min ago

A client who requires assistance with ambulation

A client who had a tonic-clonic seizure 2 hr ago

Answer and Explanation

The Correct Answer is D

A.   A client with diminished vision ambulating in well-lit areas may be at risk for falling but is not at the greatest risk among the options provided.
B.   A client who received a diuretic 30 min ago may experience orthostatic hypotension, which can increase the risk of falling, but it is not the highest risk.
C.   A client who requires assistance with ambulation is generally at a lower risk than a client who has recently experienced a tonic-clonic seizure.
D.   A client who had a tonic-clonic seizure 2 hr ago is at the greatest risk for falling due to potential residual weakness, disorientation, or postictal state following the seizure.

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Correct Answer is C

Explanation

A. Raising the index finger is not a typical response for managing gagging during NG tube insertion.

B. Bearing down during insertion is not an appropriate instruction and may increase the risk of complications.
C. Instructing the client to say "stop" if a burning sensation is felt inside the nose allows for communication and prompt action to ensure the client's comfort and safety.
D. Inhaling forcefully during insertion is not a recommended action and may interfere with the procedure.

A. The client places one crutch on each side when assuming a sitting position. B. The client places weight on the axillae when walking. C. The client moves the unaffected leg onto a step first when descending stairs. D. The client has slightly flexed elbows when ambulating with crutches.

Correct Answer is D

Explanation

A) Placing one crutch on each side when assuming a sitting position is not indicative of safe crutch use as it does not provide adequate support or balance during the transition from standing to sitting.
B) Placing weight on the axillae, or underarms, can cause nerve damage due to the pressure on the radial nerve located there; therefore, this is not a safe practice.
C) When descending stairs, the affected leg should be moved first, followed by the crutches and then the unaffected leg, to maintain balance and safety. Therefore, moving the unaffected leg onto a step first is not the safest option.
D) Having slightly flexed elbows allows for proper distribution of weight and helps in maintaining balance while ambulating with crutches, making it the correct and safe method.

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A nurse is caring for four clients. Which of the following clients is at the greatest risk for falling?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is preparing to insert an NG tube for a client who requires enteral feedings. Which of the following instructions should the nurse give the client before beginning the procedure?

Correct Answer is C

Explanation

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Correct Answer is D

Explanation

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