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 ["69"]

Explanation

Convert the weight from pounds to kilograms

190 lb * (1 kg / 2.2046 lb) = 86.183 kg (rounded to three decimal places)

The recommended dietary allowance (RDA) of protein:86.183 kg * 0.8 g/kg = 68.946 g/day

Rounding to the nearest whole number, the client should receive approximately 69 grams of protein daily.

A. Suction the client's airway. B. Empty water from the client's ventilator tubing. C. Increase the client's ventilator flow rate. D. Evaluate the client for a cuff leak.

Correct Answer is D

Explanation

D. Evaluate the client for a cuff leak is the most appropriate action in response to a low-pressure alarm on the ventilator. A cuff leak can cause a drop in ventilator pressure, triggering the alarm. Assessing the client's cuff for leaks and addressing any identified issues can help resolve the alarm and ensure adequate ventilation.
A. Suctioning the client's airway is not the appropriate action in response to a low-pressure alarm on the ventilator.
B. Emptying water from the client's ventilator tubing could be a valid action to take if there is excess condensation or water buildup in the ventilator tubing causing the low-pressure alarm. However, it's not the first action to consider, as other causes should be ruled out first.
C. Increasing the ventilator flow rate may help maintain adequate pressure in the ventilator circuit and address the low-pressure alarm if the cause is related to insufficient airflow. However, adjusting the flow rate should be done cautiously and based on the client's respiratory status and ventilator settings.

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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

Correct Answer is ["69"]

Explanation

A nurse is caring for a client who is receiving mechanical ventilation when the low-pressure alarm sounds on the ventilator. Which of the following actions should the nurse take?

Correct Answer is D

Explanation

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