A nurse is performing a fall risk assessment on a client. Which of the following findings indicates the client has an increased fall risk?
The client asks for help before ambulating.
The client has a history of urinary incontinence.
The client lives with their caregiver.
The client has bronchitis.
The Correct Answer is B
B. Urinary incontinence can increase fall risk due to the need for frequent trips to the bathroom, which may increase the chances of tripping or falling, especially if the client rushes to the bathroom.
A. This indicates that the client is aware of their limitations and is proactive in seeking assistance, which may actually decrease their fall risk. It demonstrates awareness and caution.
C. While having a caregiver present can provide support and assistance, it doesn't necessarily indicate an increased fall risk. In fact, having a caregiver present may decrease the risk of falls by providing supervision and assistance as needed.
D. Bronchitis itself does not directly contribute to an increased fall risk.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. After breaking the top of the ampule to access the medication, the nurse should dispose of the top portion safely in a sharps container to prevent accidental needlestick injuries and ensure proper disposal of sharps waste.
B. Expelling air into the ampule can increase the pressure inside, potentially causing medication to spill out or splatter when the ampule is opened.
C. To open an ampule safely, the nurse should use an ampule opener around the neck of the ampule to protect their hands from potential injury. By breaking off the top with both hands, the nurse can minimize the risk of accidental cuts or lacerations.
D. Withdrawing medication from an ampule requires the use of a needle and syringe. However, some medications may be supplied in ampules with pre-attached needleless systems for withdrawal.
Correct Answer is B
Explanation
Restraints should be avoided whenever possible. Addressing the underlying cause of wandering (such as anxiety, discomfort, or confusion) is essential.
A. In cases where restraints are deemed necessary to prevent harm to the client, such as preventing them from dislodging their tube feeding, it may be appropriate.
C. The use of an abduction pillow is a common preventive measure to maintain proper hip alignment and prevent hip dislocation, especially after hip surgery.
D. Soft heel protectors are used to prevent pressure ulcers and protect the heels from injury while the client is in bed.
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