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.

Answer and Explanation

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.

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

Explanation

B. Monitoring serum blood glucose during infusion is important because TPN can contain glucose, which may affect the client's blood glucose levels. Regular monitoring helps ensure glycemic control and prevents complications such as hyperglycemia.
C. Double-checking the TPN solution with another RN is a crucial safety measure to prevent medication errors and ensure that the correct solution is administered to the client.
E. Monitoring the client's weight daily is important for assessing fluid balance and adjusting the TPN infusion rate accordingly. Changes in weight can indicate fluid retention or loss, which may require adjustments to the TPN prescription.
A. TPN solutions must be administered according to the prescribed rate and schedule. Increasing the infusion rate without medical orders could lead to complications such as hyperglycemia or fluid overload.
D. TPN solutions are specifically formulated to meet the client's nutritional needs and cannot be substituted with other intravenous solutions like 0.9% sodium chloride.

A. Increase potassium intake. B. Decrease protein intake. C. Increase phosphorus intake. D. Decrease carbohydrate intake.

Correct Answer is B

Explanation

Clients with nephrotic syndrome should have low to normal protein diet. This is because high protein diet damages the nephrons worsening the renal insufficiency in nephrotic syndrome.

High potassium, phosphorus diet is not recommended

Adequate carbohydrate intake is key.

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A nurse is performing a fall risk assessment on a client. Which of the following findings indicates the client has an increased fall risk?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who is receiving total parenteral nutrition (TPN). Which of the following nursing actions are appropriate? (Select all that apply.)

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

Explanation

A nurse is planning care for a client who has developed nephrotic syndrome. Which of the following dietary recommendations should the nurse include?

Correct Answer is B

Explanation

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