A nurse is reviewing a fall risk assessment for a client. Which of the following findings places the client at risk for a fall? Select all that apply,

Electrical cord on floor over a walkway

Demonstrates correct use of cane to ambulate

Grab bar in the bathroom

Diagnosis of Macular degeneration

Throw rugs in kitchen

Answer and Explanation

Correct Answer : A,D,E

A. Electrical cord on floor over a walkway:
An electrical cord on the floor in a walkway poses a significant tripping hazard. Clients may not notice the cord or may have difficulty stepping over it, increasing the risk of falls, particularly for individuals with impaired mobility or vision.

B. Demonstrates correct use of cane to ambulate:
Proper use of a cane improves balance and stability, reducing fall risk rather than contributing to it. Clients who demonstrate correct usage are actively minimizing their likelihood of falling.

C. Grab bar in the bathroom:
Grab bars provide added support and stability, particularly in areas prone to slips, such as bathrooms. Their presence is a preventive measure rather than a fall risk.

D. Diagnosis of Macular degeneration:
Macular degeneration impairs central vision, which can lead to difficulties in detecting obstacles and maintaining balance, increasing the client’s susceptibility to falls.

E. Throw rugs in kitchen:
Throw rugs are a well-documented fall hazard because they can slip, bunch up, or create uneven surfaces. They are particularly risky for older adults and those with mobility impairments.

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Correct Answer is C

Explanation

A) "I will wear earphones during this test":
This statement is incorrect. The Rinne test is a hearing test used to compare air conduction to bone conduction of sound. It is performed by placing a vibrating tuning fork near the ear canal (for air conduction) and then on the mastoid bone behind the ear (for bone conduction). Earphones are not used in this test.

B) "A small probe is placed inside my ear":
This statement is incorrect. A probe is typically used for other types of hearing tests, such as tympanometry or an auditory brainstem response (ABR) test, not the Rinne test. The Rinne test involves using a tuning fork, not a probe, and the tuning fork is placed near the ear canal (for air conduction) and on the mastoid bone (for bone conduction).

C) "A tuning fork is placed on my head":
This statement is correct. In the Rinne test, the tuning fork is initially struck to produce sound and then placed on the mastoid bone (behind the ear) to test bone conduction. Afterward, the vibrating tuning fork is moved to the front of the ear canal to test air conduction. The purpose of the test is to compare these two types of conduction. If air conduction is better than bone conduction, this suggests normal hearing, while equal or better bone conduction can indicate conductive hearing loss.

D) "Small electrodes are placed on my scalp":
This statement is incorrect. Electrodes on the scalp are typically used in an electroencephalogram (EEG) or other neurodiagnostic tests, not the Rinne test. The Rinne test focuses on hearing and does not require the use of electrodes. It uses a tuning fork to assess how well sound travels through air and bone.

A. Prepares the sterile field 2 hr before it is needed B. Uses a surface that is at waist height C. Places the sterile field against a wall in the client's room D. Opens the first flap of the sterile package towards the nurse's body

Correct Answer is B

Explanation

A) Prepares the sterile field 2 hours before it is needed:
A sterile field should be prepared as close to the time it will be used as possible, typically within 15 to 30 minutes before the procedure, to ensure its sterility is maintained. Preparing a sterile field 2 hours in advance increases the risk of contamination, as airborne particles and bacteria can settle on the field during that time.

B) Uses a surface that is at waist height:
A waist-height surface is the most appropriate for setting up a sterile field. This is because it allows the nurse to maintain a proper stance and reduces the likelihood of contamination by minimizing the risk of the nurse accidentally reaching over or leaning into the sterile field. The correct height ensures that sterile items are not contaminated by being positioned too high or too low, both of which can increase the risk of contamination.

C) Places the sterile field against a wall in the client's room:
Placing the sterile field against a wall is not advisable, as it may increase the likelihood of contamination. A wall is not a sterile surface, and anything in close proximity to the wall (e.g., furniture, equipment) could inadvertently contaminate the sterile field. A sterile field should be placed on a clean, flat surface that is free from any potential contaminants, away from traffic or other surfaces that could compromise sterility.

D) Opens the first flap of the sterile package towards the nurse's body:
When opening a sterile package, the first flap should always be opened away from the body, not towards it. This action ensures that the nurse does not risk contaminating the sterile field by inadvertently touching it with their body or clothing. The nurse should open each flap of the sterile package away from themselves, then discard it, continuing to open the remaining flaps in a way that maintains the sterility of the items within.

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