A nurse is conducting a fall risk assessment for her clients. The nurse should identify that which of the following clients is the greatest risk for a fall?

An older adult who is confused and has urinary frequency

An older adult with hearing impairment

A client who has a dressing on his foot due to a pressure ulcer

A client who has osteoarthritis and uses a walker

Answer and Explanation

The Correct Answer is A

A) An older adult who is confused and has urinary frequency:
This client is at the greatest risk for a fall due to several factors. Confusion increases the likelihood of disorientation and impaired judgment, leading to accidents. Urinary frequency may necessitate frequent trips to the bathroom, increasing the chances of falls, especially if the client is disoriented or unsteady on their feet.

B) An older adult with hearing impairment:
While hearing impairment can contribute to a fall risk by limiting the client's ability to hear warnings or instructions, it may not pose as immediate a risk as confusion and urinary frequency, which directly affect mobility and judgment.

C) A client who has a dressing on his foot due to a pressure ulcer:
While having a dressing on the foot due to a pressure ulcer increases the risk of falls by potentially affecting the client's gait and balance, it may not be as significant a risk factor as confusion and urinary frequency, which directly impact the client's ability to safely navigate their environment.

D) A client who has osteoarthritis and uses a walker:
Although osteoarthritis and the use of a walker can contribute to mobility issues and an increased risk of falls, they may not present as immediate a risk as confusion and urinary frequency, which can lead to more unpredictable and hazardous situations.

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Free Nursing Study Resources

Correct Answer is ["A","B","D"]

Explanation

A) Calcium gluconate 1.5 grams IV now: Calcium gluconate is administered to counteract the effects of hyperkalemia by stabilizing the myocardial cell membrane. It does not lower potassium levels but helps protect the heart from potential dysrhythmias associated with high potassium levels.

B) Dextrose 50% injection (50ml) IV push now: Dextrose 50% injection, also known as D50W, is administered to temporarily shift potassium from the extracellular space into the intracellular space, thereby lowering serum potassium levels. It is commonly used in combination with insulin to facilitate the movement of potassium into cells.

C) Colace 100 mg PO now: Colace is a stool softener and does not affect serum potassium levels. It is not indicated for the treatment of hyperkalemia.

D) Regular insulin 10 units IV now: Regular insulin is administered with dextrose to facilitate the movement of potassium from the extracellular space into the intracellular space. Insulin stimulates the cellular uptake of glucose, which in turn drives potassium into cells along with glucose.

E) Potassium chloride 20 mEq orally now: Potassium chloride is contraindicated in the treatment of hyperkalemia as it would further increase serum potassium levels. It is typically used to supplement potassium in clients with hypokalemia, not hyperkalemia.

A. Verify the oxygen flow rate every other day. B. Post NO SMOKING signs in a prominent location in the home. C. Notify local fire department D. Apply petroleum ointment to nares if they become dry and imitated. E. Check the tops of the ears for skin breakdown.

Correct Answer is ["B","C","E"]

Explanation

B. Post NO SMOKING signs in a prominent location in the home:
Oxygen supports combustion, making smoking or exposure to open flames highly dangerous in an oxygen-enriched environment. Posting NO SMOKING signs serves as a reminder to everyone in the household to avoid smoking or using open flames near the oxygen source.

C. Notify local fire department:
It's crucial to inform the local fire department that a client is using home oxygen therapy. This ensures that emergency responders are aware of the presence of oxygen in the home in case of a fire or emergency situation.

E. Check the tops of the ears for skin breakdown:
The nasal cannula can cause pressure on the tops of the ears, potentially leading to skin breakdown, especially with prolonged use. Checking for skin breakdown and providing appropriate skin care helps prevent complications and ensures the client's comfort.

A. Verify the oxygen flow rate every other day:
While it's essential to ensure that the oxygen equipment is functioning properly and that the prescribed flow rate is appropriate for the client's needs, checking it every other day may not be necessary unless there are specific concerns or changes in the client's condition.

D. Apply petroleum ointment to nares if they become dry and irritated:
While it's common for the nasal passages to become dry with oxygen therapy, applying petroleum ointment may not be recommended without consulting the healthcare provider first, as it can interfere with oxygen delivery and increase the risk of infection.

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A nurse is conducting a fall risk assessment for her clients. The nurse should identify that which of the following clients is the greatest risk for a fall?

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Explanation

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