While the nurse is assessing an older client's fall risk, the client reports living at home alone and never falling. Which action should the nurse take?

Record a minimal risk for falls, documenting the client's statement

Place the client on a high fall risk protocol because of advanced age.

Continue to obtain client data needed to complete the fall risk survey.

Inform the client that falls occur more often in the hospital than at home.

Answer and Explanation

The Correct Answer is C

A. Relying solely on the client’s statement is insufficient for determining fall risk. A more comprehensive assessment is needed.
B. Advanced age alone does not automatically categorize a client as high risk for falls. A complete assessment should be used to evaluate risk.
C. A thorough assessment, including a fall risk survey, is essential to accurately determine the client’s risk for falling. The fact that the client has never fallen does not automatically categorize them as low risk.
D. Informing the client that falls occur more often in the hospital than at home does not address the need for an individualized risk assessment.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is ["B","D","E"]

Explanation

A. Administering insulin would be inappropriate if the client is hypoglycemic, as it would further lower the blood glucose.

B. Giving 4 ounces (120 mL) of orange juice provides a fast-acting source of glucose to treat hypoglycemia, which is likely causing confusion and weakness.

C. A diet carbonated soda contains artificial sweeteners and may not provide the immediate glucose needed in this situation.

D. Checking blood pressure and heart rate is important to assess for potential causes of the symptoms.

E. A fingerstick blood glucose test is necessary to confirm if hypoglycemia is the cause of the symptoms.

A. Record the amount of daily wound drainage. B. Turn every 2 hours around the clock from side-to-side. C. Replace fluids IV based on intake and output. D. Assess skin condition and turgor for breakdown.

Correct Answer is C

Explanation

A. Recording wound drainage is important, but fluid management takes priority due to the risk of dehydration and electrolyte imbalances.

B. Turning the client every 2 hours is helpful for preventing pressure ulcers, but fluid replacement takes precedence.

C. Clients with ulcerative colitis, especially after surgery, are at high risk for fluid and electrolyte imbalances due to diarrhea and fistula drainage. Ensuring appropriate fluid replacement is vital to maintaining hemodynamic stability.

D. Assessing skin condition is important, but it is secondary to managing fluid and electrolyte balance in this situation.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

While the nurse is assessing an older client's fall risk, the client reports living at home alone and never falling. Which action should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client newly diagnosed with diabetes mellitus suddenly becomes confused and weak. Which intervention(s) should the nurse implement? Select all that apply.

Correct Answer is ["B","D","E"]

Explanation

A client with a history of inflammatory bowel disease develops severe ulcerative colitis and is admitted to the intensive care unit after surgery for a fistula repair. Which intervention is most important for the nurse to include in the plan of care?

Correct Answer is C

Explanation

Exhibits According to the lab values, the client has dropdownrelated to dropdownordropdown.

The nurse observes an unlicensed assistive personal (UAP) washing hands prior to entering the client's room. Which action by the UAP requires additional teaching?

After removing a client's dressing that is saturated with sanguineous drainage, where should the nurse place the dressing?

The nursing staff on a medical unit includes a registered nurse (RN), practical nurse (PN), and an unlicensed assistive personnel (UAP). Which task should the charge nurse assign to the RN?

The nurse assesses a client who had bilateral total knee replacements (TKR) four hours ago. The nurse notes that the dressing on the client's right knee is saturated with serosanguineous drainage. Which action should the nurse implement?