A nurse on the medical-surgical unit is conducting a fall risk assessment for four clients. The nurse should identify that which of the following clients is the greatest risk for a fall?

A client with diabetes mellitus who has a leg ulcer

An adolescent client who has a leg fracture and has been using crutches for the past 2 days

An older adult client who is confused and has urinary frequency

A client who is 1 day postoperative and has a nursing assistant helping him out of bed

Answer and Explanation

The Correct Answer is C

A. A client with a leg ulcer may have limited mobility but not necessarily the highest fall risk.
B. An adolescent using crutches is at some risk but typically has better balance and coordination than older adults.
C. An older adult who is confused and has urinary frequency is at the highest risk for falls due to impaired cognitive function and frequent need to get up to use the bathroom, which increases the likelihood of falls.
D. A postoperative client with assistance is less likely to fall compared to an unassisted confused older adult.

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Correct Answer is C

Explanation

A. Positions the wrapped package on the bedside table so the outer flap is away from her: This action is correct because opening the flap away from the body minimizes the risk of contaminating the sterile field.

B. Holds gauze packages 15 cm (6 in) above the sterile field: This action is correct. Dropping sterile items from a height of 6 inches or more prevents contamination by ensuring they do not touch the edges or outside surfaces of the sterile field.

C. Holds a bottle of solution with the label away from the palm of the hand: When pouring a solution, the label should be held toward the palm of the hand to protect it from damage caused by spills. A damaged label could make it difficult to identify the solution, increasing the risk of error.

D. Wears sterile gloves when moving sterile items on the sterile field: This action is appropriate. Sterile gloves help maintain the sterility of the field and are required when manipulating sterile items.

A. A client received gentamicin intermittent IV bolus over 1 hr. B. A nurse injected Demerol IM into the vastus lateralis site of adult. C. A client received a crushed bupropion XL tablet mixed with applesauce. D. A nurse used a 25-gauge / inch needle to administer a heparin injection.

Correct Answer is C

Explanation

A. Gentamicin administered over 1 hour is an appropriate method for this medication.
B. Injecting Demerol IM into the vastus lateralis is an acceptable site for adults.
C. Crushing bupropion XL (extended-release) tablets is contraindicated as it alters the drug's release mechanism, which can lead to a risk of overdose or ineffective treatment, requiring an incident report.
D. Using a 25-gauge ⅝ inch needle for heparin injection is an appropriate technique.

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A nurse on the medical-surgical unit is conducting a fall risk assessment for four clients. The nurse should identify that which of the following clients is the greatest risk for a fall?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is observing a newly licensed nurse prepare a sterile field. For which of the following actions should the nurse intervene?

Correct Answer is C

Explanation

A nurse is reviewing the medication administration records from the previous shift. Which of the following findings should indicate to the nurse a need for an incident report?

Correct Answer is C

Explanation

A nurse is assessing a client's ability to ambulate with crutches using a three-point gait. Which of the following actions should the nurse identify as a risk to the client's safety?

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