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 ["121"]

Explanation

Calculation Steps:

Step 1: Convert weight from pounds to kilograms: 160 pounds ÷ 2.2 = 72.7 kg. Result = 72.7 kg.

Step 2: Calculate the total daily dose: 5 mg/kg/day × 72.7 kg = 363.5 mg/day. Result = 363.5 mg/day.

Step 3: Calculate the dose per administration: 363.5 mg/day ÷ 3 doses/day = 121.2 mg/dose. Result = 121.2 mg/dose.

Step 4: Round to the nearest whole number: 121.2 mg ≈ 121 mg.

Result = 121 mg.

A. Cefazolin 1 gram IV every 6 hours. B. Complete blood cell count (CBC) in AM. C. Advance from clear liquids as tolerated. D. Straight catheterization if unable to void.

Correct Answer is A

Explanation

Choice A reason: Administering cefazolin, an antibiotic, is a priority to prevent or treat potential infections in the immediate postoperative period.

Choice B reason: Completing a CBC in the morning is important for ongoing assessment but is not an immediate priority.

Choice C reason: Advancing the diet as tolerated is important but can be done after ensuring infection prevention.

Choice D reason: Straight catheterization is necessary if the client is unable to void but is not the immediate priority compared to preventing infection.

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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

A client who weighs 160 pounds receives a prescription for gentamicin 5 mg/kg/day IV in divided doses every 8 hours. How many mg should the nurse administer with each dose? (Enter numerical value only. If rounding is required, round to the nearest whole number.)

Correct Answer is ["121"]

Explanation

The nurse is admitting a client from the postanesthesia care unit (PACU) to the postoperative surgical care unit. Which prescription should the nurse implement first?

Correct Answer is A

Explanation

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