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 A

Explanation

Choice A rationale
The assessment component of the SBAR report includes the nurse’s evaluation of the patient’s condition, such as pain level, blood pressure, and heart rate. This information is critical for the provider to understand the patient’s current status and make informed decisions.
Choice B rationale
The situation component of the SBAR report provides a brief overview of the patient’s current situation, such as the reason for the call or the immediate concern. It does not include detailed assessment data.
Choice C rationale
The recommendation component of the SBAR report includes the nurse’s suggestions for the next steps or actions to be taken. It does not include the patient’s assessment data.
Choice D rationale
The background component of the SBAR report provides relevant medical history and context for the patient’s current condition. It does not include the detailed assessment data.

A. Ignore the error if it does not affect patient care. B. Draw a single line through the error, initial and date it. C. Leave the error as is and inform the nurse manager. D. Erase the incorrect entry and write the correct one.

Correct Answer is B

Explanation

Choice A rationale
Ignoring the error, even if it does not affect patient care, is incorrect. Ignoring errors can lead to a culture of complacency and potentially more significant errors in the future. It is essential to address all errors to maintain accurate records and ensure patient safety.
Choice B rationale
Drawing a single line through the error, initialing, and dating it is the correct action. This method maintains the integrity of the medical record while clearly indicating that an error was made and corrected. It ensures transparency and accountability in documentation.
Choice C rationale
Leaving the error as is and informing the nurse manager is not the best practice. While informing the nurse manager is important, the error should be corrected in the medical record to prevent any potential confusion or miscommunication.
Choice D rationale
Erasing the incorrect entry and writing the correct one is incorrect. Erasing or obliterating entries in a medical record is not allowed as it can be seen as tampering with the record. It is crucial to maintain the original entry and make corrections transparently.

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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 on a medical-surgical unit is preparing to contact a provider about a client’s condition. The nurse notes the client’s post-op pain is 8/10, BP is 140/90, and HR is 110. The nurse should include information about the client in which component of the SBAR report?

Correct Answer is A

Explanation

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Correct Answer is B

Explanation

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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.