A nurse caring for patients in a long-term care facility knows that there are factors that place certain patients at a higher risk for falls.
Which patients would the nurse consider to be in this category? Select all that apply.

A patient who experiences postural hypotension.

A patient who is experiencing nausea from chemotherapy.

A patient who has already fallen twice.

A patient who is older than 50 years old.

A patient who is transferred to long-term care.

Answer and Explanation

Correct Answer : A,C,E

Choice A rationale
A patient who experiences postural hypotension is at a higher risk for falls. Postural hypotension, or a sudden drop in blood pressure upon standing, can cause dizziness and increase the likelihood of falling. This condition is common in older adults and those with certain medical conditions.
Choice B rationale
A patient who is experiencing nausea from chemotherapy is not necessarily at a higher risk for falls. While nausea can cause discomfort and weakness, it does not directly contribute to an increased risk of falling. Other factors, such as medication side effects or balance issues, are more significant in fall risk assessment.
Choice C rationale

A patient who has already fallen twice is at a higher risk for future falls. A history of falls is a strong predictor of subsequent falls, as it may indicate underlying issues such as balance problems, muscle weakness, or environmental hazards.
Choice D rationale
A patient who is older than 50 years old is not automatically at a higher risk for falls. While age is a factor, the risk significantly increases for individuals over 65 years old. Other factors, such as medical conditions and medication use, play a more critical role in fall risk assessment.
Choice E rationale
A patient who is transferred to long-term care is at a higher risk for falls. The transition to a new environment can be disorienting, and patients may be unfamiliar with their surroundings. Additionally, long-term care patients often have multiple health issues that contribute to an increased fall risk.

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Correct Answer is B

Explanation

Choice A rationale
Asking for an order for an incentive spirometer is a recommendation, which belongs in the R step of SBAR. The B step should provide background information about the patient’s condition.
Choice B rationale
Providing the client’s history of sleep apnea is appropriate for the B step, which involves giving background information relevant to the current situation.
Choice C rationale
Describing the client’s current respirations and temperature is part of the Assessment step, not the Background step. The B step should focus on the patient’s medical history and relevant background information.
Choice D rationale
Stating that the client was found unconscious on the floor is part of the Situation step, not the Background step. The B step should provide background information about the patient’s condition.

A. Report the incident to the organization. B. Inform the patient about the breach. C. Ask the unauthorized personnel to delete the information. D. Ignore the incident unless someone reports it.

Correct Answer is A

Explanation

Choice A rationale
Report the incident to the organization. According to HIPAA, the first step a healthcare provider should take after an accidental disclosure of patient information is to report the incident to the organization. This allows the organization to assess the breach, determine the extent of the disclosure, and take appropriate actions to mitigate any potential harm.
Choice B rationale
Inform the patient about the breach. While informing the patient is important, it is not the first step. The organization must first assess the breach and determine the appropriate course of action before notifying the patient.

Choice C rationale
Ask the unauthorized personnel to delete the information. This step may be part of the mitigation process, but it is not the first step. The incident must first be reported to the organization for proper assessment and documentation.
Choice D rationale
Ignore the incident unless someone reports it. This response is inappropriate and violates HIPAA regulations. All breaches must be reported and addressed promptly to ensure compliance with HIPAA and protect patient privacy.

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A nurse caring for patients in a long-term care facility knows that there are factors that place certain patients at a higher risk for falls. Which patients would the nurse consider to be in this category? Select all that apply.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is planning to use the SBAR communication tool when calling a provider. Which of the following statements should the nurse include in the B step?

Correct Answer is B

Explanation

A healthcare provider accidentally discloses a patient’s regulations. What should the provider do first according to HIPAA?

Correct Answer is A

Explanation

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After administration of an antihypertensive medication, the nurse notes the client’s blood pressure decreases by 10 points. Which part of the nursing process is being fulfilled?

A nurse caring for patients in a long-term care facility knows that there are factors that place certain patients at a higher risk for falls.
Which patients would the nurse consider to be in this category? Select all that apply.