A nurse is developing a plan of care for an older adult client who has osteoporosis. Which of the following interventions to prevent falls should the nurse include in the plan?

Instruct the client to use the hallway grab bars when walking.

Assist the client to the bathroom every 4 hr.

Administer an antianxiety medication at bedtime.

Monitor the client's activity every 2 hr.

Answer and Explanation

The Correct Answer is A

A. Instruct the client to use the hallway grab bars when walking. This is correct. Using hallway grab bars provides support and stability, helping to prevent falls in clients with osteoporosis.
B. Assist the client to the bathroom every 4 hr. Assisting the client to the bathroom regularly is important, but every 4 hours might not be frequent enough and doesn't directly address fall prevention throughout all activities.
C. Administer an antianxiety medication at bedtime. Antianxiety medications can cause sedation and increase the risk of falls, especially in older adults.
D. Monitor the client's activity every 2 hr. Monitoring the client’s activity is important, but this does not provide specific fall prevention strategies or interventions.

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Correct Answer is B

Explanation

A. Hold sterile supplies 7.6 cm (3 in) above the sterile field. Sterile supplies should be held at least 15-20 cm (6-8 inches) above the sterile field to avoid contamination.
B. Drop sterile objects toward the center of the sterile field. This minimizes the risk of contamination by keeping the edges of the field sterile.
C. Open the first flap of the sterile tray packaging toward himself. The first flap should be opened away from the nurse to avoid reaching over the sterile field.
D. Hold bottles of sterile fluid with the label facing outward. The label should face inward (toward the nurse) to protect it from spills and ensure visibility of the label.

A. "My mother had a heart attack at 60 years old." B. "I will be 50 years old on my birthday this year." C. "My latest cholesterol level was 190." D. "I have a BMI of 28."

Correct Answer is C

Explanation

A. "My mother had a heart attack at 60 years old." Family history of cardiovascular disease is a risk factor, but this statement alone doesn’t provide a full picture of the client’s risk without other factors.
B. "I will be 50 years old on my birthday this year." Age is a risk factor for cardiovascular disease, but being 50 alone does not necessarily indicate an elevated risk without considering other factors like lifestyle and health status.
C. "My latest cholesterol level was 190." A cholesterol level of 190 mg/dL is borderline high and can be a risk factor for cardiovascular disease. This statement is indicative of a potential risk factor.
D. "I have a BMI of 28." A BMI of 28 indicates overweight, which is a risk factor for cardiovascular disease. This is a relevant indicator of risk but is not the only factor to consider.

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A nurse is developing a plan of care for an older adult client who has osteoporosis. Which of the following interventions to prevent falls should the nurse include in the plan?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is B

Explanation

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Correct Answer is C

Explanation

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