A nurse is developing a plan of care for an older adult who is at risk for falls. Which of the following actions should the nurse plan to include in the plan? (Select all that apply)

Place the bedside table within the client's reach.

Teach balance and strengthening exercises.

Provide information about home safety checks.

Administer sedative at bedtime.

Lock beds and wheelchairs when not providing care.

Answer and Explanation

Correct Answer : A,B,C,E

A) Place the bedside table within the client's reach: This is an important safety measure to help prevent falls. By ensuring that the bedside table is within easy reach, the client will be less likely to try to reach for objects outside their immediate area, reducing the risk of falls from overextending or getting up unnecessarily.

B) Teach balance and strengthening exercises: Teaching balance and strengthening exercises is a key preventative measure for older adults at risk for falls. These exercises help improve muscle strength, coordination, and stability, which can significantly reduce the likelihood of falls.

C) Provide information about home safety checks: Providing information about home safety is essential to prevent falls in older adults. This includes advising the patient on eliminating hazards (like loose rugs, clutter, or inadequate lighting) and ensuring that the home environment is conducive to safety. A home safety check is part of creating a fall-prevention strategy.

D) Administer sedative at bedtime: Administering sedatives to older adults, especially those at risk for falls, can increase the likelihood of confusion, dizziness, or impaired coordination, which can lead to falls. This is not a recommended intervention. Non-pharmacologic methods for improving sleep hygiene should be prioritized over sedative medications when possible.

E) Lock beds and wheelchairs when not providing care: Locking beds and wheelchairs when not in use is a fundamental safety measure to prevent accidental movement of the bed or wheelchair. This action reduces the risk of the patient falling out of bed or from a wheelchair if they try to move or shift positions.

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Correct Answer is B

Explanation

A) The client is a male: While gender can influence the risk of certain health conditions, being male is not generally considered a major risk factor for acquiring a health care-associated infection (HAI). Other factors, such as age, immune status, and recent surgical procedures, are more directly linked to HAI risk.

B) The client is 71 years old: Older adults are at a higher risk for acquiring healthcare-associated infections due to age-related changes in the immune system, decreased skin integrity, and the likelihood of having multiple chronic conditions. The decreased immune response in elderly individuals makes them more susceptible to infections, including those acquired in healthcare settings.

C) The client had an appendectomy 6 months ago: While past surgeries can contribute to the risk of infections, the fact that the client had an appendectomy 6 months ago does not directly indicate a current risk for acquiring an HAI. Typically, the risk of postoperative infections decreases over time as the wound heals, especially if the surgery occurred months ago.

D) The client has bipolar disorder: Although bipolar disorder can affect a person's mental health and compliance with medical treatments, it is not a direct risk factor for acquiring a healthcare-associated infection. The focus in HAI risk assessment is generally on physical health factors such as age, immune status, surgical history, and other clinical factors rather than mental health conditions.

A. A nurse who works for an insurance company and collects urine samples from clients who have HIV B. A personal trainer who works with a client who has HIV C. A phlebotomist who collects blood from clients who have HIV D. An occupational therapist who works with a client who has HIV

Correct Answer is C

Explanation

A) A nurse who works for an insurance company and collects urine samples from clients who have HIV: While this nurse may interact with clients who have HIV, collecting urine samples does not typically pose a significant risk for HIV transmission. HIV is not transmitted through urine, and the nurse would not be in direct contact with blood or bodily fluids that present a risk.

B) A personal trainer who works with a client who has HIV: A personal trainer is at low risk for contracting HIV while working with a client who has the virus, provided there is no direct exposure to blood or open wounds. HIV is transmitted through specific bodily fluids such as blood, semen, vaginal fluids, and breast milk, and not through casual contact or physical activity like exercise.
C) A phlebotomist who collects blood from clients who have HIV: A phlebotomist is at the greatest risk of contracting HIV because they handle blood directly. If proper precautions, such as gloves and safe needle handling, are not followed, there is an increased risk of exposure to HIV-infected blood. Occupational exposure to blood is one of the most significant routes of HIV transmission in healthcare settings.

D) An occupational therapist who works with a client who has HIV: An occupational therapist working with a client who has HIV is at a low risk of contracting HIV, provided the therapist does not come into direct contact with blood or other potentially infectious bodily fluids. Occupational therapy generally involves helping clients with physical or cognitive tasks and does not typically present a risk for HIV transmission unless there is a breach in infection control practices.

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A nurse is developing a plan of care for an older adult who is at risk for falls. Which of the following actions should the nurse plan to include in the plan? (Select all that apply)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is reviewing the medical record for a client who has a health care-associated infection (HAI). The nurse should identify which of the following findings as a risk factor for acquiring an HAI?

Correct Answer is B

Explanation

A group of nurses are discussing risk factors for transmission of human immunodeficiency virus (HIV) from clients: Which of the following individuals should the nurse identify as being at the greatest risk for contracting HIV?

Correct Answer is C

Explanation

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