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 B

Explanation

A. A serum creatinine level of 0.8 mg/dL is within the normal range and does not contraindicate the administration of cefoxitin.
B. A severe allergy to amoxicillin indicates a potential cross-allergy with cephalosporins like cefoxitin, making it a contraindication for administration.
C. A recent history of diarrhea is not typically a contraindication for administering cefoxitin, unless it is severe or related to a specific infectious cause.
D. A history of phlebitis from a previous IV infusion is not a contraindication for cefoxitin unless it suggests an intolerance to certain infusion components.

A. Lactated Ringer's B. 3% sodium chloride C. 0.9% sodium chloride D. Dextrose 10% in water

Correct Answer is D

Explanation

A. Lactated Ringer's does not provide the necessary glucose to prevent hypoglycemia in clients receiving TPN.
B. 3% sodium chloride is hypertonic and not appropriate for preventing hypoglycemia.
C. 0.9% sodium chloride does not provide the necessary glucose.
D. Dextrose 10% in water (D10W) provides a glucose source to help prevent hypoglycemia in clients when TPN is temporarily unavailable.

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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 reviewing the medical record of a client who is to receive the first dose of cefoxitin via intermittent IV bolus. Which of the following findings should the nurse identify as a contraindication for the client to receive cefoxitin and report to the provider?

Correct Answer is B

Explanation

Correct Answer is D

Explanation

Exhibits The nurse inspects the airway. There is no visible trauma, and the airway appears to be patent. What other assessment items are included in the primary survey? Select all that apply.

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