A nurse is caring for a patient on a medical-surgical unit.

Exhibits

A nurse is performing a fall risk assessment on a patient. Which of the following findings indicate that the patient is at increased risk for falls? Select all that apply

WBC Count

Parkinson’s disease

Potassium level on day 2

Furosemide

Low blood pressure

Answer and Explanation

Correct Answer : B,C,D,E

Choice A: WBC Count

Reason: The white blood cell (WBC) count is not directly related to fall risk. WBC count is an indicator of the immune system’s response to infection or inflammation. In this case, the patient’s WBC count is within the normal range (5,000 to 10,000/mm³) on both days. Therefore, it does not contribute to an increased risk of falls.

Choice B: Parkinson’s disease

Reason: Parkinson’s disease significantly increases the risk of falls due to several factors. Patients with Parkinson’s often experience postural instability, which is the inability to maintain balance when standing or walking. This condition is a cardinal feature of Parkinson’s disease and can lead to frequent falls. Additionally, Parkinson’s patients may experience freezing of gait, where they suddenly cannot move their feet forward despite the intention to walk. This can cause them to fall. Other gait abnormalities, such as festinating gait (short, rapid steps) and dyskinesias (involuntary movements), also contribute to the increased fall risk.

Choice C: Potassium level on day 2

Reason: The patient’s potassium level on day 2 is 3.0 mEq/L, which is below the normal range of 3.5 to 5 mEq/L. Low potassium levels (hypokalemia) can lead to muscle weakness, cramps, and fatigue. These symptoms can impair the patient’s ability to maintain balance and increase the risk of falls. Hypokalemia can also cause abnormal heart rhythms, which can further contribute to the risk of falls.

Choice D: Furosemide

Reason: Furosemide is a diuretic medication used to treat conditions such as heart failure by reducing fluid buildup in the body. However, it can also cause orthostatic hypotension, a condition where blood pressure drops significantly when standing up. This can lead to dizziness, lightheadedness, and an increased risk of falls. Additionally, furosemide can cause electrolyte imbalances, such as low potassium levels, which can further contribute to fall risk.

Choice E: Low blood pressure

Reason: The patient’s blood pressure readings indicate orthostatic hypotension, with a significant drop from 128/56 mm Hg while sitting to 92/40 mm Hg while standing. Orthostatic hypotension is a common condition in patients with Parkinson’s disease and heart failure. It can cause dizziness, lightheadedness, and fainting when changing positions, increasing the risk of falls. The patient’s low blood pressure when standing is a clear indicator of increased fall risk.

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Correct Answer is C

Explanation

Choice A reason: I’ll Be Sure to Eat More Foods with Vitamin K

This statement indicates a misunderstanding. While vitamin K is essential for blood clotting, consuming large amounts of vitamin K can interfere with the effectiveness of warfarin. Patients on warfarin should maintain a consistent intake of vitamin K to avoid fluctuations in their INR levels.

Choice B reason: I’ll Take Aspirin for My Headaches

This statement also indicates a misunderstanding. Aspirin and other nonsteroidal anti-inflammatory drugs (NSAIDs) can increase the risk of bleeding when taken with warfarin. Patients should consult their healthcare provider before taking any new medications, including over-the-counter drugs.

Choice C reason: I’ll Use My Electric Razor for Shaving

This statement indicates an understanding of the teaching. Using an electric razor instead of a traditional blade can help prevent cuts and bleeding, which is particularly important for patients on anticoagulant therapy like warfarin.

Choice D reason: It’s Okay to Have a Couple of Glasses of Wine with Dinner Each Evening

This statement indicates a misunderstanding. Alcohol can affect the metabolism of warfarin and increase the risk of bleeding. Patients on warfarin should limit their alcohol intake and discuss their drinking habits with their healthcare provider to ensure safe use of the medication.

Correct Answer is ["0.2"]

Explanation

Step 1: Determine the concentration of morphine sulfate available. = 10 mg/mL

Step 2: Determine the dose of morphine sulfate to be administered. = 2 mg

Step 3: Calculate the volume to be administered using the formula: Volume to be administered = Dose ÷ Concentration

Step 4: Perform the division. Calculation: 2 mg ÷ 10 mg/mL = 0.2 mL

Step 5: Round the answer to the nearest tenth if necessary. = 0.2 mL (no rounding needed)

The nurse should administer 0.2 mL per dose.

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A nurse is caring for a patient on a medical-surgical unit. Exhibits A nurse is performing a fall risk assessment on a patient. Which of the following findings indicate that the patient is at increased risk for falls? Select all that apply

Choice A: WBC Count

Choice B: Parkinson’s disease

Choice C: Potassium level on day 2

Choice D: Furosemide

Choice E: Low blood pressure

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is providing discharge teaching to a client who has a new prescription for warfarin. Which of the following statements by the client indicates an understanding of the teaching?

Correct Answer is C

Explanation

A nurse is preparing to administer morphine sulfate 2 mg IV bolus. Available is morphine sulfate 10 mg/mL. How many mL should the nurse administer per dose? (Round the answer to the nearest tenth. Use a leading zero if it applies. Do not use a trailing zero.)

Correct Answer is ["0.2"]

Explanation

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A nurse is caring for a patient on a medical-surgical unit. Exhibits A nurse is performing a fall risk assessment on a patient. Which of the following findings indicate that the patient is at increased risk for falls? Select all that apply

A nurse is caring for a patient on a medical-surgical unit.

Exhibits

A nurse is performing a fall risk assessment on a patient. Which of the following findings indicate that the patient is at increased risk for falls? Select all that apply