The practical nurse (PN) reviews the history of an older adult who is newly admitted to a long-term care facility. Which factor in the resident's history should the PN consider the most likely to increase the client's risk for falls?

Ankle ulcer that is healing slowly.

History of alcohol abuse and cigarete smoking.

Recent weight gain of twenty pounds.

Newly prescribed antihypertensive medication.

Answer and Explanation

The Correct Answer is D

This is the factor that the PN should consider the most likely to increase the client's risk for falls because it can cause orthostatic hypotension, dizziness, or fainting, especially when the client changes position or gets up from bed or a chair. The PN should monitor the client's blood pressure and pulse before and after administering the medication and assist the client with ambulation and transfers.

A. An ankle ulcer that is healing slowly is not a major risk factor for falls and may not aﬀect the client's mobility or balance.

B. History of alcohol abuse and cigarette smoking is not a major risk factor for falls unless the client is currently intoxicated or has a chronic lung disease that impairs oxygenation or cognition.

C. Recent weight gain of twenty pounds is not a major risk factor for falls unless it causes joint pain, edema, or difficulty moving.

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Correct Answer is C

Explanation

The correct answer is Choice C. Soft blanket.

Choice A rationale:

A heating pad should not be applied to the client's legs with a mottled appearance. A mottled appearance indicates poor circulation, and applying heat could potentially worsen the situation by dilating blood vessels and further reducing blood flow to the extremities.

Choice B rationale:

The body lotion is not appropriate in this situation. While it may help moisturize the skin, it will not address the underlying circulation issues causing the mottled appearance. Moreover, applying lotions to areas with compromised circulation can be harmful.

Choice C rationale:

The correct choice. A soft blanket can be applied to the client's legs with a mottled appearance to provide warmth and comfort. It is essential to keep the client comfortable during palliative care, and a soft blanket can help maintain a suitable temperature without causing harm.

Choice D rationale:

Moist clothes are not indicated in this situation. They may potentially worsen the mottled appearance by adding moisture to the skin, and it won't address the circulation issues causing the discoloration.

A. Oﬀer the client a prescribed sleep medication. B. Reposition the client and provide a back rub. C. Administer an as-needed (PRN) prescription for pain. D. Provide a cup of hot chocolate at bedtime.

Correct Answer is B

Explanation

This is the best initial intervention for the PN to implement because it promotes comfort, relaxation, and circulation for the client. A back rub can also reduce anxiety and muscle tension, which can interfere with sleep. The PN should use non-pharmacological methods to facilitate sleep before resorting to medication.

A. Oﬀering the client a prescribed sleep medication is not the best initial intervention because it may have side eﬀects or interactions with other drugs. The PN should assess the client's need for medication and use it as a last resort.

C. Administering an as-needed (PRN) prescription for pain is not the best initial intervention because it may not address the cause of the client's difficulty in sleeping. The PN should assess the client's pain level and use other methods to relieve pain before giving medication.

D. Providing a cup of hot chocolate at bedtime is not the best initial intervention because it may contain caﬀeine, which can stimulate the central nervous system and keep the client awake. The PN should avoid giving caﬀeinated beverages to the client before bedtime.

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The practical nurse (PN) reviews the history of an older adult who is newly admitted to a long-term care facility. Which factor in the resident's history should the PN consider the most likely to increase the client's risk for falls?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client is receiving palliative care, and death is anticipated within the next 24 hours. The practical nurse (PN) observes that the client's legs have a mottled appearance. What should the PN apply to the client's legs?

Correct Answer is C

Explanation

A client who had orthopedic surgery three days ago verbalizes difficulty in sleeping. Which initial intervention is best for the practical nurse (PN) to implement?

Correct Answer is B

Explanation

The practical nurse (PN) is reviewing instructions for the use of pilocarpine eye drops with a client who has glaucoma. The client states, "I should use these drops to anesthetize my eye if I experience eye pain.”. Which action should the PN implement?

The practical nurse (PN) is preparing for shift change. Which task has the highest priority and should be completed first?

A client who had knee replacement surgery receives a prescription for enoxaparin 30 mg subcutaneously every 12 hours for 10 days. The medication is available in 30 mg per 0.3 mL prefilled syringes. How many mL should the practical nurse (PN) administer each day? (Enter numerical value only.).

The unlicensed assistive personnel (UAP) tells the practical nurse (PN) that a male client is angry because the night shift took over 2 hours to bring him the pain medication he had to request three times. Which action should the PN implement first?

The practical nurse (PN) is caring for a client who has a prescription for loratadine by mouth daily as needed. Which sign indicates to the PN that there is a need to administer the medication?

Which intervention is most important for the practical nurse (PN) to implement for a client who is receiving total parenteral nutrition (TPN)?

A male client who has just been told he has cancer asks the practical nurse (PN) to leave his room so he can be alone. Which action should the PN implement?

A 70-year-old male client who is convalescing from a hip replacement is identified as being at risk for developing a pressure ulcer. Which physical characteristic of aging contributes most to this risk factor?