A nurse is assessing an older adult client’s risk for falls.
Which assessments should the nurse use to identify the client’s safety needs? (Select all that apply)

Pupil clarity

Appearance of gait

Visual fields

Visual acuity

Answer and Explanation

Correct Answer : B,C,D

Choice A rationale

Pupil clarity is not typically used to assess an older adult client’s risk for falls. It is more relevant in neurological assessments.

Choice B rationale

The appearance of gait is a crucial factor in assessing an older adult client’s risk for falls. Abnormalities in gait can increase the risk of falls.

Choice C rationale

Visual fields are important in assessing an older adult client’s risk for falls. Impaired visual fields can increase the risk of falls.

Choice D rationale

Visual acuity is important in assessing an older adult client’s risk for falls. Poor visual acuity can increase the risk of falls.

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Correct Answer is B

Explanation

Choice A rationale

The route of administration, “by mouth”, is clearly stated in the prescription. Therefore, there is no need to confirm this with the healthcare provider.

Choice B rationale

The dosage of the medication, “0.25”, is not specified in terms of units (e.g., milligrams, micrograms). This could lead to errors in medication administration. Therefore, the nurse should confirm the dosage of the medication with the healthcare provider.

Choice C rationale

The frequency of administration, “daily”, is clearly stated in the prescription. Therefore, there is no need to confirm this with the healthcare provider.

Choice D rationale

The name of the medication, “digoxin”, is clearly stated in the prescription. Therefore, there is no need to confirm this with the healthcare provider.

Correct Answer is ["8"]

Explanation

Step 1 is: Calculate the total units of heparin in the bag, which is 25,000 units.

Step 2 is: Divide the total units by the total volume to find the units per mL, which is (25,000 units ÷ 250 mL) = 100 units/mL.

Step 3 is: Divide the desired units per hour by the units per mL to find the mL/hr, which is (800 units/hr ÷ 100 units/mL) = 8 mL/hr. So, the infusion pump rate should be set at 8 mL/hr.

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A nurse is assessing an older adult client’s risk for falls.Which assessments should the nurse use to identify the client’s safety needs? (Select all that apply)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is examining a patient’s medication prescription which states, “digoxin 0.25 by mouth daily.”. Which component of the prescription should the nurse confirm with the healthcare provider?

Correct Answer is B

Explanation

Correct Answer is ["8"]

Explanation

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A nurse is assessing an older adult client’s risk for falls.
Which assessments should the nurse use to identify the client’s safety needs? (Select all that apply)