A home health nurse is performing a fall risk assessment for an older adult client. Which of the following findings should the nurse identify as a potential fall risk in the home?

The client has electrical wires secured to baseboards.

The client wears rubber-sole shoes.

The client's visual acuity is 20/40.

The client takes an antihypertensive medication.

Answer and Explanation

The Correct Answer is D

A. Securing electrical wires reduces tripping hazards and promotes safety.

B. Rubber-sole shoes provide better traction and reduce the risk of slips and falls.

C. Reduced visual acuity increases the risk of falls but not as much as taking antihypertensives do.

D. Taking an antihypertensive medication can be a potential fall risk, because it can cause hypotension and dizziness.

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Free Nursing Study Resources

Correct Answer is A

Explanation

A. Obtaining the client's type and cross-match is the first action the nurse should take because it ensures that the client will have compatible blood available for transfusion if needed during surgery.
B. This is important but should only be done after obtaining the client’s type and cross-match.
C. This should be done after obtaining the client’s type and cross-match.

D. While an incident report may be necessary, the immediate priority is to address the oversight and ensure patient safety.

A. Use sterile gloves when removing the old dressing B. Change the dressing four times per day. C. Clean from the incision to the surrounding skin. D. Apply tincture of benzoin prior to removing the dressing

Correct Answer is C

Explanation

A. Clean gloves are typically sufficient for wound care, and the use of sterile gloves may not be necessary for routine dressing changes.
B. Frequent dressing changes can disrupt wound healing and increase the risk of infection. Dressings should be changed according to the healthcare provider's instructions, which are typically less frequent.
C. When cleaning the wound, it is important to start from the incision site and work outward to avoid introducing contaminants into the wound.
D. Tincture of benzoin is a skin adhesive and may not be routinely used for dressing changes, especially if it is not specified in the healthcare provider's orders.

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A home health nurse is performing a fall risk assessment for an older adult client. Which of the following findings should the nurse identify as a potential fall risk in the home?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

During change-of-shift report, a nurse discovers they overlooked a prescription for a type and cross-match of a client who is to have surgery the next day. Which of the following actions should the nurse take first?

Correct Answer is A

Explanation

A nurse is providing discharge teaching to the partner of a client who has a linear incision site following an open cholecystectomy. Which of the following wound care instructions should the nurse include?

Correct Answer is C

Explanation

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