Nokea
The nurse is performing a fall risk assessment on a group of clients. It would be appropriate for the nurse to identify the client at risk for falls who. Select all that apply.
- A. Is an older adult.
- B. Has a history of two previous falls
- C. Taking oral antibiotics.
- D. Experiences postural hypotension.
- E. Wearing non-slip shoes.
Correct Answer: A,B,D
Rationale: Older adults, those with prior falls, and postural hypotension increase fall risk. Oral antibiotics and non-slip shoes do not contribute to fall risk.
You may also like to solve these questions
A nurse is caring for a 90-year-old client who has been bedridden at home for two weeks. Which of the following is not an expected finding due to immobility?
- A. A decrease in bone density
- B. Loss of short-term memory
- C. Atelectasis
- D. High serum calcium level
Correct Answer: B
Rationale: Immobility causes bone density loss, atelectasis, and high serum calcium due to bone resorption, but short-term memory loss is not directly related to immobility.
The nurse works on a medical-surgical unit and is responsible for assessing the client's vital signs. Which of the following clients can have their temperature measured orally? Select all that apply.
- A. A 61-year-old woman who had oral surgery
- B. A 44-year old man with chest pain on oxygen via nasal canula
- C. An 83-year-old woman with diarrhea
- D. A 29-year-old client with an earache
- E. A 6-year-old client with a sore throat and difficulty swallowing
Correct Answer: B,C,D
Rationale: Oral temperature is safe for clients with chest pain, diarrhea, or earache, as they have no oral contraindications. Oral surgery and difficulty swallowing contraindicate oral measurement.
The infection control nurse is responding to an outbreak of norovirus in the facility. The nurse should recommend that
- A. staff wears a surgical mask when providing client care.
- B. disposable utensils and dishware are used for meals.
- C. dietary staff wears a face shield when preparing client meals.
- D. commonly touched surfaces be disinfected with a bleach solution.
Correct Answer: D
Rationale: Norovirus requires contact precautions, including bleach disinfection of surfaces. Masks, disposable utensils, and face shields are not standard.
The nurse is caring for a client who is two days postoperative following a right femoral popliteal bypass surgery. The client reports worsening pain, and the assessment showed swelling and ecchymosis at the incision sites. The nurse should initially
- A. Apply pressure to sites with sandbag
- B. Palpate pedal pulses
- C. Assess for signs of claudication
- D. Apply warm compress to incision sites
Correct Answer: B
Rationale: Worsening pain, swelling, and ecchymosis at the incision sites suggest possible complications such as hematoma or compromised vascular flow. Palpating pedal pulses is the priority to assess the patency of the bypass graft and ensure adequate distal perfusion. Applying pressure or warm compresses could exacerbate bleeding or swelling, and claudication assessment is less urgent than confirming vascular integrity.
The nurse is caring for a client three hours postoperative following a laparoscopic appendectomy. Which of the following client data indicates the client is ready for discharge home?
- A. Positive gag reflex
- B. Hypoactive bowel sounds
- C. Blood pressure 90/60 mm Hg
- D. Incisional pain '2' on a scale of 0 to 10
- E. Urinary output of 240 mL since surgery
Correct Answer: A,D,E
Rationale: A positive gag reflex indicates airway protection, mild incisional pain (2/10) suggests adequate pain control, and sufficient urinary output (240 mL) indicates renal function, all supporting discharge readiness. Low blood pressure (90/60 mm Hg) suggests instability, and hypoactive bowel sounds are expected but not a discharge criterion.