A home health care nurse is conducting a fall risk assessment for a client who has osteoarthritis and lives alone. The nurse should identify that which of the following factors creates a risk for falls?

Large pieces of furniture.

A bedside table next to the bed.

Raised toilet seats.

Throw rugs on hardwood floors.

Answer and Explanation

The Correct Answer is D

Choice A rationale:

Large pieces of furniture do not necessarily create a significant risk for falls unless they are poorly placed or obstructing pathways. While they can potentially cause accidents, the likelihood of tripping over them is generally lower compared to other hazards.

Choice B rationale:

A bedside table next to the bed is not a significant fall risk factor. In fact, having a bedside table can be beneficial for the client, as it provides a convenient surface for placing items that the client might need during the night.

Choice C rationale:

Raised toilet seats, although they may pose a challenge for individuals with mobility issues, are typically installed to aid those with difficulty sitting down or standing up. They are not a primary risk factor for falls, especially when compared to other more hazardous factors.

Choice D rationale:

Throw rugs on hardwood floors are a significant fall risk factor, especially for older adults or individuals with mobility problems. The rugs can easily shift or bunch up, causing someone to trip and fall. Hardwood floors can also become slippery, and the combination of a throw rug on such a surface increases the risk of accidents. The rationale behind this choice is grounded in the potential for tripping and slipping hazards that these throw rugs can introduce, especially in individuals who might already have balance or mobility issues.

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Correct Answer is D

Explanation

When handling an unused portion of an oral opioid analgesic after administration, the nurse should take the following action:

D) Return the unused portion to the locked narcotics storage location.

Returning the unused portion to the locked narcotics storage location is a crucial step to ensure proper control and documentation of controlled substances like opioids. It helps prevent diversion and ensures the security and accountability of these medications.

Options A, B, and C are not appropriate:

A) Sending the unused portion to the pharmacy is not typically the responsibility of the nurse, and it may not be a practical or safe option for controlled substances.

B) Having a second nurse verify disposal of the unused portion is not a standard practice for oral medication administration.

C) Keeping the unused portion in the client's medication drawer is not an appropriate method of handling unused controlled substances, as it lacks the necessary security and accountability measures.

A. Client's present condition. B. Suggestions for the provider regarding client care. C. Physical findings. D. Previous treatments.

Correct Answer is A

Explanation

Choice A rationale:

In the "background" portion of the SBAR communication tool, the nurse should include the client's present condition. This information provides the provider with context and a clear understanding of the client's current status. It helps the provider to have a baseline understanding before moving on to the assessment and recommendation stages of the communication. Including the client's present condition allows the provider to quickly grasp the urgency and severity of the situation, enabling them to make informed decisions regarding the client's care.

Choice B rationale:

Suggestions for the provider regarding client care are typically included in the "assessment" or "recommendation" portions of the SBAR communication tool, rather than the "background" portion. The "background" portion is focused on providing information about the current situation and the client's present condition, setting the stage for the rest of the communication.

Choice C rationale:

Physical findings are part of the assessment and observation of the client's current condition. While important, these findings are better suited for the "assessment" portion of the SBAR communication. The nurse should summarize the physical findings in the "assessment" section after providing the context in the "background" section.

Choice D rationale:

Previous treatments are also relevant information, but they belong in the "assessment" or "background" portions of the SBAR communication tool. The nurse should provide the provider with information about the client's current condition before discussing previous treatments, as the provider needs to know the current situation before considering the relevance of past interventions.

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A home health care nurse is conducting a fall risk assessment for a client who has osteoarthritis and lives alone. The nurse should identify that which of the following factors creates a risk for falls?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is preparing to administer an oral opioid analgesic to a client. Which of the following actions should the nurse take when handling an unused portion of the medication after administration?

Correct Answer is D

Explanation

A nurse is preparing to notify the provider about a change in a client's status. Which of the following information should the nurse plan to include in the "background" portion of the Situation, Background, Assessment, Recommendation (SBAR) Communication tool?

Correct Answer is A

Explanation

A nurse is teaching a client to manage stress by using progressive relaxation techniques. Which of the following statements by the client indicates an understanding of the teaching?

A nurse is receiving change-of-shift report for four clients. Which of the following clients should the nurse assess first?

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A nurse is setting up a sterile field prior to changing a client's dressing. Which of the following actions should the nurse take?

A nurse is planning care for a client who reports having difficulty sleeping. Which of the following interventions should the nurse include in the plan of care?

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A nurse is performing a focused assessment of a client's sensory functions. Which of the following tests should the nurse perform?