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A nurse in a provider's office is caring for a client.

Exhibits
The nurse is performing a fall risk assessment for the client. Select the 3 findings that place the client at risk for a fall.

Prescribed medication

Blood pressure readings

Gait

Reports of home environment

Voiding pattern

Answer and Explanation

Correct Answer : A,B,E

Rationale for correct choices:

Prescribed medication: The client is taking hydrochlorothiazide, a diuretic that can cause dizziness, orthostatic hypotension, and increased nighttime urination. These side effects increase the risk for falls, especially in older adults who may already have mobility limitations.
Blood pressure readings: The client’s blood pressure dropped from sitting 138/84 mm Hg to standing 100/70 mm Hg, indicating orthostatic hypotension. This sudden decrease in blood pressure can cause lightheadedness, dizziness, or fainting, all of which increase the likelihood of falls.
Voiding pattern: The client reports waking 2–3 times per night to void. Nocturia increases fall risk because the client must get up in low-light conditions, potentially while drowsy, making them more susceptible to tripping or losing balance.

Rationale for incorrect choices:

Gait: The client’s gait is steady, and no abnormalities were noted during assessment. While gait disturbances can increase fall risk, in this case, the client’s mobility does not currently contribute to risk.
Reports of home environment: The client has already removed throw rugs and increased lighting, implementing effective fall prevention strategies at home. Therefore, the home environment does not currently place the client at increased risk for falls.

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Free Nursing Study Resources

Correct Answer is ["B","C","E"]

Explanation

Rationale for correct choices:

Insert a large-bore IV catheter: A large-bore IV (18–20 gauge) is necessary to allow rapid administration of blood products and reduce hemolysis of red blood cells during transfusion. This ensures safe and effective delivery of the blood components.
Witness the client signing a consent for transfusion: Informed consent is required before initiating a blood transfusion. The nurse ensures that the client understands the purpose, risks, and potential complications, and witnesses the signing to meet legal and ethical standards.
Have a second nurse confirm the information on the blood lab: Verifying the blood type, crossmatch, and client identifiers with a second nurse reduces the risk of transfusion errors and ensures patient safety before starting the transfusion.

Rationale for incorrect choices:

Explain to the client that transfusion reactions are not serious: Transfusion reactions can be serious, including hemolytic reactions, febrile reactions, or allergic responses. The nurse should educate the client on the potential risks and signs of a reaction rather than minimizing them.
Flush the transfusion tubing with dextrose 5% in water: Blood products should only be administered with 0.9% sodium chloride (normal saline). Flushing with dextrose or other solutions can cause hemolysis and compromise the safety of the transfusion.

A. "I don't think you understand the risks to your health." B. "You should talk with your family about it first." C. "I will notify your provider regarding this decision." D. "Let me remind you of the benefits of the surgery."

Correct Answer is C

Explanation

Rationale:

A. "I don't think you understand the risks to your health.": This response is dismissive of the client’s autonomy and implies the nurse is questioning the client’s decision-making ability. It can create a defensive reaction rather than supporting informed consent.

B. "You should talk with your family about it first.": While family support can be helpful, the decision for surgery ultimately rests with the client. Suggesting family involvement at this point could undermine the client’s right to make an independent healthcare decision.

C. "I will notify your provider regarding this decision.": This response respects the client’s autonomy and ensures the healthcare team is promptly informed. It also facilitates further discussion between the provider and client about the decision, ensuring it is fully informed.

D. "Let me remind you of the benefits of the surgery.": While reviewing benefits can be part of informed consent, doing so after the client has expressed a clear decision not to proceed may be perceived as coercive rather than supportive.

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A nursery nurse is attending the birth of a post-term infant.

Exhibits

Drag words from the choices below to fill in each blank in the following sentence.

Upon review of the medical record, the nurse should determine the infant newborn is at risk for developing

and .

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A nurse in a provider's office is caring for a client. Exhibits The nurse is performing a fall risk assessment for the client. Select the 3 findings that place the client at risk for a fall.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse reviews the entries in the medical record. Exhibits The nurse is preparing the client for a blood transfusion, which of the following actions should the nurse take? Select all that apply.

Correct Answer is ["B","C","E"]

Explanation

A nurse is caring for a client who is scheduled for surgery. The client states, "I have decided not to have the surgery." Which of the following responses should the nurse make to the client?

Correct Answer is C

Explanation

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A nursery nurse is attending the birth of a post-term infant. Exhibits Drag words from the choices below to fill in each blank in the following sentence. Upon review of the medical record, the nurse should determine the infant newborn is at risk for developing dropdown and dropdown.

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A nurse in a provider's office is caring for a client.

Exhibits
The nurse is performing a fall risk assessment for the client. Select the 3 findings that place the client at risk for a fall.