A nurse is conducting a fall risk assessment for her clients. The nurse should identify that which of the following clients is the greatest risk for a fall?

An older adult who is confused and has urinary frequency

An older adult with hearing impairment

A client who has a dressing on his foot due to a pressure ulcer

A client who has osteoarthritis and uses a walker

Answer and Explanation

The Correct Answer is A

A) An older adult who is confused and has urinary frequency:
This client is at the greatest risk for a fall due to several factors. Confusion increases the likelihood of disorientation and impaired judgment, leading to accidents. Urinary frequency may necessitate frequent trips to the bathroom, increasing the chances of falls, especially if the client is disoriented or unsteady on their feet.

B) An older adult with hearing impairment:
While hearing impairment can contribute to a fall risk by limiting the client's ability to hear warnings or instructions, it may not pose as immediate a risk as confusion and urinary frequency, which directly affect mobility and judgment.

C) A client who has a dressing on his foot due to a pressure ulcer:
While having a dressing on the foot due to a pressure ulcer increases the risk of falls by potentially affecting the client's gait and balance, it may not be as significant a risk factor as confusion and urinary frequency, which directly impact the client's ability to safely navigate their environment.

D) A client who has osteoarthritis and uses a walker:
Although osteoarthritis and the use of a walker can contribute to mobility issues and an increased risk of falls, they may not present as immediate a risk as confusion and urinary frequency, which can lead to more unpredictable and hazardous situations.

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Correct Answer is B

Explanation

Answer: B. The padding of the restraints is against the client's bony prominences.

A. The nurse can insert one finger between the client's wrist and the restraint.
The proper guideline is that the nurse should be able to insert two fingers between the client's wrist and the restraint. This ensures the restraint is snug but not too tight, which helps prevent impaired circulation and skin breakdown.

B. The padding of the restraints is against the client's bony prominences.
This is the correct practice. The padding of the restraints should always be applied to protect the client’s skin and prevent injury, particularly over bony prominences where the risk of pressure sores or skin breakdown is higher.

C. The AP ties the straps of the restraints in a double knot.
A double knot should not be used because it can make it difficult to quickly release the restraint in an emergency. A quick-release knot should always be used to ensure the restraint can be removed easily and promptly if needed.

D. The AP ties the restraints to the side rails.
Restraints should never be tied to movable parts like side rails, as raising or lowering the side rails could cause injury. Restraints should be secured to a part of the bed frame that does not move to prevent harm to the client.

A. Check residual volume every 4 to 6 hr. B. Observe client's respiratory status. C. Elevate the head of the client's bed 30" to 45". D. Monitor intake and output every 8 hr.

Correct Answer is C

Explanation

A. Check residual volume every 4 to 6 hr: While checking residual volume is an essential component of enteral feeding management, it is not the priority action in this scenario. The client's positioning to prevent aspiration takes precedence over checking residual volume.

B. Observe client's respiratory status: Monitoring respiratory status is crucial for any client with a decreased level of consciousness. However, in this case, the priority is to prevent aspiration, and positioning takes precedence over respiratory assessment.

C. Elevate the head of the client's bed 30° to 45°: The priority action for a client receiving continuous enteral feedings via a gastrostomy tube and experiencing a decreased level of consciousness is to maintain proper positioning to prevent aspiration. Elevating the head of the bed 30° to 45° helps reduce the risk of aspiration by promoting drainage of stomach contents away from the airway. This position also helps prevent reflux of gastric contents into the esophagus, which can lead to aspiration pneumonia.

D. Monitor intake and output every 8 hr: Monitoring intake and output is essential for assessing fluid balance and the effectiveness of enteral feedings. However, it is not the priority action in this situation compared to maintaining proper positioning to prevent aspiration.

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A nurse is conducting a fall risk assessment for her clients. The nurse should identify that which of the following clients is the greatest risk for a fall?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse manager is observing an AP applying wrist restraints for a client. Which of the following actions should the nurse identify as an indication that the AP understands the procedure?

Correct Answer is B

Explanation

A nurse is planning care for a client who has a decreased level of consciousness. The client is receiving continuous enteral feedings via a gastrostomy tube due to an inability to swallow. Which of the following is the priority action by the nurse?

Correct Answer is C

Explanation

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