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?

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.

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

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

Answer and Explanation

The Correct Answer is A

Choice A reason: Completing the fall risk survey provides a comprehensive assessment of the client's fall risk, considering all factors.

Choice B reason: Informing the client that falls occur more often in the hospital does not complete the assessment.

Choice C reason: Recording a minimal risk based solely on the client's statement may not accurately reflect the true fall risk.

Choice D reason: Placing the client on high fall risk protocol based on age alone is not appropriate without a complete assessment.

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Correct Answer is C

Explanation

Choice A reason: Evaluating a client's mobility progress involves assessment and clinical judgment, which are beyond the scope of practice for a UAP.

Choice B reason: Titrating oxygen requires clinical judgment and understanding of the client's condition, which should be performed by licensed nursing staff.

Choice C reason: Procuring platelet products from the blood bank is within the scope of practice for a UAP as it involves following protocols and retrieving items, not direct patient care.

Choice D reason: Determining the diameter and depth of a client's dermal ulcer involves assessment and clinical judgment, which should be performed by licensed nursing staff.

A. Catheter tubing. B. The client's bed. C. Urinary meatus. D. Client's bladder.

Correct Answer is A

Explanation

Choice A reason: The catheter tubing is the most likely reservoir for the infection as it can harbor bacteria and introduce them into the urinary tract when not managed properly.

Choice B reason: The client's bed is an unlikely reservoir for the infection as it does not have direct contact with the urinary system.

Choice C reason: The urinary meatus is part of the normal flora but is not the primary reservoir for the infection in this scenario.

Choice D reason: The client's bladder is the site of the infection, not the reservoir that introduced the bacteria.

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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

The nurse leading a care team on a medical surgical unit is assigning client care to a practical nurse (PN) and an unlicensed assistive personnel (UAP). Which activity should the nurse assign to the UAP?

Correct Answer is C

Explanation

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Correct Answer is A

Explanation

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