A nurse is reviewing a fall risk assessment for a client.
Which of the following findings place the client at risk for a fall? Select all that apply.

Electrical cord on floor over walkway.

Uses a cane to ambulate.

Unsecured throw rugs over tile floor in kitchen.

Macular degeneration.

Answer and Explanation

Correct Answer : A,C,D

Choice A rationale
An electrical cord on the floor over a walkway can pose a tripping hazard, increasing the risk of falls. It’s important to keep walkways clear of any obstacles to prevent falls.
Choice B rationale
Using a cane to ambulate does not necessarily increase the risk of falls. In fact, canes are often used to improve balance and stability, reducing the risk of falls. However, it’s important that the cane is used correctly and is the right height for the individual.
Choice C rationale
Unsecured throw rugs, especially over a slippery surface like a tile floor, can easily cause someone to slip and fall. It’s recommended to secure rugs with non-slip backing or remove them entirely from high-traffic areas.
Choice D rationale
Macular degeneration can lead to vision loss, which can increase the risk of falls. Individuals with vision impairments may not be able to see hazards in their path, making them more prone to falls.

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Correct Answer is D

Explanation

Choice A rationale
Fairness refers to treating all people equally and making decisions without favoritism or prejudice. This is not the most fitting answer because the scenario does not provide information about the nurse treating all patients equally.
Choice B rationale
Confidence in nursing involves trust in one’s abilities and clinical judgment. Although confidence is important in all nursing actions, this scenario does not specifically highlight the nurse’s confidence.

Choice C rationale
Advocacy in nursing refers to the nurse’s role in standing up for the rights and needs of their patient. While notifying the provider could be seen as a form of advocacy, the nurse’s actions in this scenario are more closely aligned with accountability.
Choice D rationale
Accountability in nursing refers to the responsibility of nurses to execute their duties according to standards, being answerable for their actions. In this scenario, the nurse demonstrates accountability by acknowledging the medication error, assessing the patient for any adverse effects, and reporting the incident.

A. Lock the wheels on the patient’s bed. B. Position the chair at a 90-degree angle to the bed. C. Elevate the patient’s bed. D. Place the chair on the patient’s left side.

Correct Answer is A

Explanation

Choice A rationale
Locking the wheels on the patient’s bed is a safety measure that should be taken to prevent the bed from moving during the transfer.
Choice B rationale
Positioning the chair at a 90-degree angle to the bed could make the transfer more difficult. It’s usually recommended to position the chair parallel to the bed.
Choice C rationale
Elevating the patient’s bed isn’t typically necessary for a transfer and could potentially make the transfer more difficult.
Choice D rationale
Placing the chair on the patient’s left side, the side of the patient’s weakness, could make the transfer more difficult. It’s usually recommended to lead with the patient’s stronger side.

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A nurse is reviewing a fall risk assessment for a client. Which of the following findings place the client at risk for a fall? Select all that apply.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is D

Explanation

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Correct Answer is A

Explanation

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A nurse is reviewing a fall risk assessment for a client.
Which of the following findings place the client at risk for a fall? Select all that apply.