Nokea
The nurse is performing a home safety assessment for an older adult. What environmental factors should be considered when assessing the client for risk for falls?
- A. Cognitive impairment
- B. Vision loss
- C. Hearing loss
- D. Adequate lighting
Correct Answer: B,D
Rationale: Vision loss and inadequate lighting are environmental factors increasing fall risk. Cognitive and hearing impairments are client-specific, not environmental.
You may also like to solve these questions
The nurse is caring for a post-operative client at high risk for pneumonia. Which intervention would be most effective in the prevention of this complication?
- A. Passive range of motion
- B. Sequential compression devices (SCDs)
- C. Early ambulation
- D. Prophylactic antibiotics
Correct Answer: C
Rationale: Early ambulation promotes lung expansion and secretion clearance, reducing pneumonia risk. Other options are less effective for this purpose.
The nurse is starting a peripheral vascular access device for a client. The nurse inserted the device into the vein and observed a flashback of blood in the chamber. The nurse should then
- A. Advance the VAD approximately 3 inches (7.62 cm) into the vein and loosen the stylet.
- B. Remove the stylet and secure the catheter using a transparent dressing.
- C. Advance the VAD approximately 1/4 inch (0.6 cm) into the vein and loosen the stylet.
- D. Remove the stylet and release the tourniquet.
Correct Answer: D
Rationale: After observing a blood flashback, the nurse should remove the stylet and release the tourniquet to prevent hematoma formation, then secure the catheter. Advancing further risks vein damage or dislodgement, and securing without releasing the tourniquet is incorrect.
The nurse is discussing the risk of delayed wound healing following surgery with another healthcare team member. It would be correct for the nurse to identify which condition is a potential cause of this complication?
- A. Diabetes insipidus
- B. Cushing's syndrome
- C. Hemophilia
- D. Inflammatory bowel disease
Correct Answer: B
Rationale: Cushing’s syndrome involves elevated cortisol levels, which impair wound healing by suppressing immune responses and collagen synthesis. Diabetes insipidus primarily affects fluid balance, hemophilia affects clotting but not healing directly, and inflammatory bowel disease is less directly related to wound healing compared to Cushing’s syndrome.
The nurse is caring for an older adult following a total hip arthroplasty. The nurse should anticipate a prescription for which postoperative medication?
- A. Hydrocortisone
- B. Enoxaparin
- C. Metoprolol
- D. Furosemide
- E. Morphine
Correct Answer: B,E
Rationale: Enoxaparin prevents venous thromboembolism, a common risk post-hip arthroplasty, and morphine manages postoperative pain. Hydrocortisone, metoprolol, and furosemide are not routinely prescribed unless indicated by specific conditions.
The nurse is reviewing the vital signs of a client admitted with atrial fibrillation. The client's vital signs are: T 37.5°C (99.6°F), P 88 and irregular, RR 20, BP 90/56 mmHg, pulse oximetry reading 96% on room air. The nurse should immediately address which vital sign?
- A. Temperature
- B. Blood pressure
- C. Respiratory rate
- D. Pulse
Correct Answer: B
Rationale: Low BP (90/56 mmHg) indicates potential hemodynamic instability, requiring immediate attention in atrial fibrillation. Temperature, respiratory rate, and pulse are less critical.