A nurse is assessing a client to determine their fall risk. Which of the following findings should alert the nurse that the client is at risk for falls?

1+ pedal edema

Bruises on the lower extremities

Impaired vision

Coarse rhonchi auscultated over the trachea

Answer and Explanation

The Correct Answer is C

A. 1+ pedal edema. Mild pedal edema is typically not associated with instability or falls, unless it progresses to severe swelling that affects mobility or balance. It is a sign of fluid retention but not a direct fall risk indicator on its own.
B. Bruises on the lower extremities. Bruising can be a sign of previous falls or trauma, but it is not itself a cause or indicator of fall risk. While it may prompt further investigation, it does not confirm fall risk independently.
C. Impaired vision. Visual impairment is a significant risk factor for falls because it affects depth perception, ability to detect hazards, and overall spatial awareness. Clients with impaired vision are more likely to trip, misjudge steps, or bump into obstacles.
D. Coarse rhonchi auscultated over the trachea. Coarse rhonchi are respiratory findings typically related to mucus in the airways and do not directly contribute to fall risk unless accompanied by severe respiratory distress or fatigue.

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Correct Answer is A

Explanation

A. The stoma appears dark purple in color. This is a priority finding, as it may indicate impaired circulation or necrosis of the stoma tissue. A healthy stoma should appear pink or red and moist. A dark purple or black color requires immediate evaluation.
B. The colostomy has had no output. While it is important to monitor output, it is not unusual for a new colostomy to have minimal or no output in the first 24–48 hours post-op as bowel function returns.
C. The client refuses to look at the colostomy. This is a psychosocial concern and may indicate body image issues or denial, but it is not the most urgent issue in the immediate postoperative period.
D. The client reports a pain level of 6 on a scale from 0 to 10. Pain management is important, but a pain level of 6, while needing intervention, does not take priority over a potential vascular compromise of the stoma.

A. Aspirin 1 tablet daily B. Furosemide 20 mg BID C. Nitroglycerin transdermal patch D. Metoprolol 5 mg now

Correct Answer is B

Explanation

A. Aspirin 1 tablet daily. This prescription is incomplete because it does not specify the dose in milligrams. Aspirin comes in multiple strengths, and clarity is essential to ensure safe administration.
B. Furosemide 20 mg BID. This prescription is complete because it includes the medication name, dosage (20 mg), and frequency (twice daily). It provides all necessary components for safe administration.
C. Nitroglycerin transdermal patch. This order lacks critical details such as the dosage, frequency, and duration of use. Without this information, the prescription is incomplete and cannot be safely implemented.
D. Metoprolol 5 mg now. Although it includes the medication, dosage, and timing, it does not specify the route (e.g., oral, IV), which is necessary for the prescription to be considered complete.

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A nurse is assessing a client to determine their fall risk. Which of the following findings should alert the nurse that the client is at risk for falls?

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