The nurse is caring for several patients on a medical unit.
Which patient does the nurse identify as being most at risk for falling?

An adult patient who has left arm weakness secondary to a childhood injury.

An elderly patient who requires eye glasses for reading small print on labels and newspapers.

A patient who is confused and experiencing nausea due to a head injury.

A patient who uses the grab bars located in the hospital bathroom.

Answer and Explanation

The Correct Answer is C

Choice A rationale:

While a patient with left arm weakness may have some mobility limitations, it does not necessarily put them at the highest risk for falling compared to the other options provided.

Choice B rationale:

Needing glasses for reading small print does not directly indicate a high risk of falling. The patient can still have good overall mobility and balance.

Choice C rationale:

A confused patient experiencing nausea due to a head injury is at the highest risk for falling. Confusion impairs judgment and decision-making abilities, increasing the likelihood of accidents. Nausea can further destabilize the patient, making them prone to falls.

Choice D rationale:

Using grab bars in the hospital bathroom indicates that the patient is aware of their limitations and is taking precautions to prevent falls. This does not suggest a higher risk compared to a confused and nauseous patient.

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Correct Answer is B

Explanation

Choice A rationale:

Placing the pulse oximeter probe on a finger with slow or delayed capillary refill can lead to inaccurate readings. Slow capillary refill indicates poor peripheral perfusion, which may affect the accuracy of pulse oximetry readings. The nurse should select a finger with normal capillary refill to obtain accurate readings.

Choice B rationale:

Documenting the pulse oximeter reading as a percent is the correct action. Pulse oximeter readings are expressed as percentages, representing the oxygen saturation level in the patient's blood. Normal oxygen saturation levels typically range from 95% to 100%. Documenting the reading in percent allows healthcare providers to monitor the patient's oxygenation status accurately.

Choice C rationale:

Assuring that the reading is taken in bright light, such as sunlight or fluorescent light, is incorrect. Bright light can interfere with the accuracy of pulse oximetry readings by causing the sensor to misinterpret external light as a pulsatile signal. To obtain accurate readings, the pulse oximeter should be used in a well-lit environment but away from direct bright light sources.

Choice D rationale:

Avoiding the removal of dark nail polish before obtaining the reading is incorrect. Dark nail polish can interfere with the pulse oximeter's ability to detect the pulsatile signal from the patient's finger, leading to inaccurate oxygen saturation readings. The nurse should advise the patient to remove dark nail polish or choose another finger without nail polish for the measurement.

A. "You don't need to worry about anything. B. We will get home health care set up for you.”. C. "I heard your son was arrested for driving while intoxicated, will he be there to help you care for your incision?". D. "I am sure you can't wait to go home.

Correct Answer is D

No explanation

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The nurse is caring for several patients on a medical unit.Which patient does the nurse identify as being most at risk for falling?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is B

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The nurse is caring for several patients on a medical unit.
Which patient does the nurse identify as being most at risk for falling?