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 B
Explanation
B. Muscle weakness can be a sign of digoxin toxicity, and it is essential for the client to notify their healthcare provider if they experience this symptom. Muscle weakness is a potential adverse effect of digoxin, especially if the medication level in the blood becomes too high.
A. While constipation is a potential side effect of digoxin, taking it with fiber is not a recommended method for preventing constipation.
C. Blurred vision can be a sign of digoxin toxicity, and the client should not increase their dose if they experience this symptom. Instead, they should promptly notify their healthcare provider to assess for toxicity and adjust the medication regimen as needed.
D. Digoxin is a medication that can slow the heart rate, and a pulse rate less than 60 beats per minute is considered bradycardia. If the client's pulse is less than 60 beats per minute, they should hold the digoxin and promptly notify their healthcare provider.
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.
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