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A nurse is reviewing a fall risk assessment for a client. Which of the following findings places the client at risk for a fall? Select all that apply.
- A. Electrical cord on floor over a walkway
- B. Demonstrates correct use of cane to ambulate
- C. Grab bar in the bathroom
- D. Diagnosis of macular degeneration
- E. Throw rugs in kitchen
Correct Answer: A,D,E
Rationale: Correct Answer: A, D, E
Rationale:
- A: An electrical cord on the floor is a tripping hazard, increasing the risk of falls.
- D: Macular degeneration affects vision, leading to difficulties in depth perception and obstacle detection, increasing fall risk.
- E: Throw rugs in the kitchen can cause slipping or tripping, posing a fall hazard.
Summary of Incorrect Choices:
- B: Demonstrating correct use of a cane indicates the client is taking precautions to prevent falls.
- C: Having a grab bar in the bathroom is a safety measure to prevent falls.
- F and G: Not provided in the question, so cannot be evaluated.
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A nurse in a public clinic is planning a health fair for older adult clients in the community. In teaching medication safety, which of the following foods should the nurse advise the clients to avoid when taking their prescriptions?
- A. Orange juice
- B. Grapefruit juice
- C. Milk
- D. Carbonated beverage
Correct Answer: B
Rationale: The correct answer is B: Grapefruit juice. Grapefruit juice can interact with many medications by inhibiting the enzyme that metabolizes the drugs, leading to higher drug levels in the body and potentially causing adverse effects. Orange juice (A), milk (C), and carbonated beverages (D) do not have significant interactions with most medications. It is important for the nurse to advise older adult clients to avoid grapefruit juice to prevent medication interactions and ensure their safety.
A nurse opens a unit-dose of a prescribed medication prior to administering it to a client. After education, the client refuses to take the medication. Which of the following actions should the nurse take?
- A. Notify the facility’s ethics committee
- B. Return the opened medication to the medication cart
- C. Report the incident to the provider
- D. Fill out an incident report
Correct Answer: C
Rationale: The correct answer is C: Report the incident to the provider. The nurse should report the client's refusal to take the medication to the provider to ensure appropriate documentation and follow-up care. This step is crucial for the client's safety and well-being.
A: Notifying the ethics committee is not necessary in this situation as the provider should be the first point of contact.
B: Returning the opened medication to the cart is inappropriate and unsafe as it could lead to medication errors.
D: Filling out an incident report may be necessary, but reporting to the provider should be the immediate action.
In summary, option C is the correct choice as it prioritizes the client's care and ensures proper communication with the healthcare provider.
A client is to receive enoxaparin 30 mg subcutaneously. Available is enoxaparin 40 mg/mL. How many mL should the nurse administer? (Round the answer to the nearest tenth. Use a leading zero if it applies. Do not use a trailing zero.)
Correct Answer: 0.8
Rationale: The correct answer is 0.8 mL. To determine this, divide the desired dose (30 mg) by the concentration (40 mg/mL) to get 0.75. Since we need to round to the nearest tenth, 0.75 rounds up to 0.8 mL. The other choices are incorrect because: A: 0.7 mL, B: 0.9 mL, C: 0.6 mL, D: 1.0 mL, E: 0.5 mL, F: 1.2 mL, G: 0.3 mL. These choices do not accurately reflect the calculated dose based on the given information.
A nurse is observing a newly licensed nurse set up a sterile field. Which of the following actions by the newly licensed nurse indicates an understanding of the procedure?
- A. Prepares the sterile field 2 hr before it is needed
- B. Uses a surface that is at waist height
- C. Places the sterile field against a wall in the client's room
- D. Opens the first flap of the sterile package towards the nurse's body
Correct Answer: B
Rationale: The correct answer is B because setting up a sterile field at waist height minimizes the risk of contamination. This position ensures better visibility and accessibility for the nurse while maintaining sterility. Choice A is incorrect as preparing the sterile field too early can lead to contamination. Choice C is incorrect as placing the sterile field against a wall increases the risk of contamination from the wall. Choice D is incorrect because the first flap should be opened away from the body to prevent contamination.
A charge nurse is reviewing the documentation completed by a newly licensed nurse. Which of the following entries should the charge nurse recommend for revision?
- A. The client demonstrated proper technique when drawing up 8 units of insulin
- B. The client stated ‘I struggle to see those little lines on the syringe’
- C. The client FBS was 95 mg/dL
- D. The client seems to be more comfortable performing self-administration of insulin
Correct Answer: D
Rationale: The correct answer is D. The charge nurse should recommend revising this entry because it implies the client is self-administering insulin, which is beyond the scope of practice for a client. This could lead to serious harm if not addressed.
A, B, and C are incorrect because they all indicate proper client care and documentation. A shows proper technique, B indicates client's concern with syringe lines, and C provides the client's fasting blood sugar level.