A nurse is conducting a fall risk assessment for a patient.
Which of the following factors would increase the patient’s risk of falling?

The presence of a grab bar in the bathroom.

An electrical cord lying across a walkway.

The patient has macular degeneration.

There are throw rugs in the kitchen.

The patient uses a cane to ambulate.

Answer and Explanation

Correct Answer : B,C,D,E

Choice A rationale

The presence of a grab bar in the bathroom is actually a safety measure that can help prevent falls. It provides support for the patient when they are getting up or moving around, reducing the risk of a fall.

Choice B rationale

An electrical cord lying across a walkway is a tripping hazard and would increase the patient’s risk of falling. It is important to keep walkways clear of clutter and potential obstacles to prevent falls.

Choice C rationale

Macular degeneration can affect the patient’s vision, making it difficult for them to see obstacles or changes in the walking surface. This can increase their risk of falling.

Choice D rationale

Throw rugs in the kitchen can easily slip or bunch up, creating a tripping hazard. They should be secured with non-slip backing or removed to reduce the risk of falls.

Choice E rationale

While a cane can provide support and improve balance, it also indicates that the patient has mobility issues, which increases their risk of falling. It is important that the patient uses the cane correctly and that it is the right height for them.

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Correct Answer is A

Explanation

A pale stoma can indicate poor blood flow, which is a serious concern that should be reported to the provider immediately. A healthy stoma should be moist and dark red or pink in color.

A. Fill the balloon with the recommended sterile water. B. Remove the catheter, wipe with alcohol, and reinsert after lubrication. C. Leave the catheter in the vagina as a landmark for insertion of a new, sterile catheter. D. Discard the catheter and begin again.

Correct Answer is C

Explanation

If the nurse suspects the catheter is not in the urethra, they should leave the catheter in the vagina as a landmark for insertion of a new, sterile catheter.

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A nurse is conducting a fall risk assessment for a patient.Which of the following factors would increase the patient’s risk of falling?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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A nurse is conducting a fall risk assessment for a patient.
Which of the following factors would increase the patient’s risk of falling?