A nurse is admitting a client to a geriatric medicine unit. Which action would the nurse implement to reduce the clients risk for falling?

Provide the client with a bedpan to reduce ambulating to the restroom

Administer pain medications sparingly in order to minimize any cognitive side effects

Place the client in a shared room with a client who is stable and oriented

Orient the client to the room and environment upon admission

Answer and Explanation

The Correct Answer is D

A. Provide the client with a bedpan to reduce ambulating to the restroom: While limiting unnecessary movement can help prevent falls, using a bedpan is not the best intervention unless the patient is completely immobile.

B. Administer pain medications sparingly in order to minimize any cognitive side effects: Undertreating pain can lead to restlessness and unsteady movement, which may increase fall risk rather than prevent it.

C. Place the client in a shared room with a client who is stable and oriented: Roommate selection does not directly reduce fall risk. A shared room does not guarantee supervision or fall prevention.

D. Orient the client to the room and environment upon admission: Older adults may be disoriented in a new environment, increasing fall risk. Orienting them to the room (call light, bathroom location, bed height) helps them move safely.

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Correct Answer is A

Explanation

A. Educate the patient about hand hygiene with alcohol-based hand sanitizer: Standard precautions apply to all patients, including hand hygiene education. HIV is not transmitted through casual contact.

B. Notify the patient's spouse about the result and arrange for HIV testing: Patient confidentiality must be maintained. The patient should be encouraged to inform their partner, but the nurse cannot disclose the results.

C. Provide information on antibiotic therapy to help control the infection: HIV is a viral infection, not bacterial. Antibiotics do not treat HIV.

D. Initiate contact precautions with gown and gloves: HIV is bloodborne and not spread via casual contact, so contact precautions are not required unless the patient has an open wound or secondary infection.

A. Check the patient's urinalysis. B. Notify the provider of the patient's pain 7/10 C. Perform a bladder scan D. Assess the daily weight.

Correct Answer is C

Explanation

A. Check the patient's urinalysis. While a urinalysis may provide useful information (e.g., infection, kidney function), it does not address the immediate concern—significantly decreased urine output despite adequate intake. The priority is to determine urinary retention first.

B. Notify the provider of the patient's pain 7/10. While pain management is important, the more critical issue is the drastically low urine output (150mL in 12 hours), which could indicate acute urinary retention or renal dysfunction. Addressing the urinary issue should come first.

C. Perform a bladder scan. The low urine output (150mL in 12 hours) despite sufficient intake (2150mL) suggests potential urinary retention. A bladder scan is the quickest and least invasive way to determine if the patient has a full bladder that needs intervention (e.g., catheterization). This is the priority before further testing or notifying the provider.

D. Assess the daily weight. Daily weight monitoring is helpful for fluid status assessment, especially in cases of heart failure or kidney disease, but it is not the most immediate priority. The primary concern is whether the patient has urinary retention, which requires urgent evaluation.

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Laboratory Test	Reference Range	Patient Results
White Blood Cells	5,000- 10,000/mm3	9,500/mm3
Neutrophil Count	2.500-8,000/mm3	5,200/mm3
HIV	Negative	Positive

A nurse is admitting a client to a geriatric medicine unit. Which action would the nurse implement to reduce the clients risk for falling?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is A

Explanation

Correct Answer is C

Explanation

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