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 B

Explanation

Choice A reason: Continuing with the blood pressure assessment without acknowledging the auscultatory gap may result in an inaccurate reading.

Choice B reason: Noting the presence of an auscultatory gap is important as it indicates a brief period when Korotkoff sounds disappear and then reappear, which can lead to underestimation of systolic blood pressure and overestimation of diastolic blood pressure if not recognized.

Choice C reason: Repositioning the stethoscope may not address the issue of the auscultatory gap and may lead to inaccurate readings.

Choice D reason: Re-inflating the cuff to a higher number is unnecessary and may cause discomfort without addressing the auscultatory gap.

A. Place an indwelling urinary catheter and institute strict intake and output measurements. B. Secure client consent for coronary angiography and percutaneous coronary intervention. C. Administer four 81 mg aspirin tablets providing instructions to chew before swallowing. D. Evaluate upper and lower extremities for perfusion, pulse volume, and pitting edema.

Correct Answer is C

Explanation

Choice A reason: Placing an indwelling urinary catheter and instituting strict intake and output measurements can be done later if needed, but addressing the chest pain is the priority.

Choice B reason: Securing consent for coronary angiography and intervention is important but should be done after addressing the immediate chest pain and potential myocardial infarction.

Choice C reason: Administering aspirin is crucial as it acts as an antiplatelet agent, helping to reduce the risk of further clot formation and improving outcomes in the setting of acute coronary syndrome.

Choice D reason: Evaluating extremities for perfusion is important but secondary to administering aspirin in this acute situation.

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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?

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Naxlex Comprehensive Predictor Exams

After inflating a blood pressure cuff and releasing the valve, the nurse hears silence followed by a Korotkoff sound. Which action should the nurse take next?

Correct Answer is B

Explanation

A client with a history of unstable angina presents to the emergency department with constant chest pressure that is unrelieved with rest. The client appears anxious, pale, and diaphoretic. After obtaining the client's vital signs, which action should the nurse take next?

Correct Answer is C

Explanation

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