A nurse is reviewing a fall risk assessment for a client.
Which of the following findings place the client at risk for a fall? Select all that apply.
Electrical cord on floor over walkway.
Uses a cane to ambulate.
Unsecured throw rugs over tile floor in kitchen.
Macular degeneration.
Correct Answer : A,C,D
Choice A rationale
An electrical cord on the floor over a walkway can pose a tripping hazard, increasing the risk of falls. It’s important to keep walkways clear of any obstacles to prevent falls.
Choice B rationale
Using a cane to ambulate does not necessarily increase the risk of falls. In fact, canes are often used to improve balance and stability, reducing the risk of falls. However, it’s important that the cane is used correctly and is the right height for the individual.
Choice C rationale
Unsecured throw rugs, especially over a slippery surface like a tile floor, can easily cause someone to slip and fall. It’s recommended to secure rugs with non-slip backing or remove them entirely from high-traffic areas.
Choice D rationale
Macular degeneration can lead to vision loss, which can increase the risk of falls. Individuals with vision impairments may not be able to see hazards in their path, making them more prone to falls.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale
Before repositioning a patient, the nurse should first elevate the height of the patient’s bed. This allows the nurse to work at a comfortable height and reduces the risk of injury.
Choice B rationale
While tightening the abdominal muscles can help with lifting and moving, it is not the first action the nurse should take when preparing to reposition a patient.
Choice C rationale
Positioning the feet in line with the shoulders can provide a stable base of support when moving or lifting. However, this is not the first action the nurse should take when preparing to reposition a patient.
Choice D rationale
Pivoting the feet in the direction of the move can help with turning and moving. However, this is not the first action the nurse should take when preparing to reposition a patient.
Correct Answer is B
Explanation
Choice A rationale
Holding the pain medication until the patient wakes up is not the best choice. Pain can disrupt sleep, and it’s important to keep the patient as comfortable as possible. If the patient is sleeping, it may be because the pain is well-controlled, and delaying the medication could lead to a return of pain.
Choice B rationale
The patient should be given the scheduled pain medication. This is the best choice because it ensures that the patient’s pain is managed effectively. Even if the patient is sleeping, the medication should be given to prevent the pain from returning.
Choice C rationale
Calling the family and asking if the patient would like to be woken up to have their pain medication is not the best choice. The nurse should make this decision based on the patient’s pain level and the medication schedule, not on the family’s preferences.
Choice D rationale
The statement that the patient has become addicted to the medication and is sleeping the last dose off is not accurate. Addiction is a complex condition characterized by compulsive drug use despite harmful consequences. In this case, the patient is receiving the medication for a legitimate medical reason, and there is no indication of addiction.
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