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

Electrical cord on floor over a walkway

Demonstrates correct use of cane to ambulate

Grab bar in the bathroom

Diagnosis of Macular degeneration

Throw rugs in kitchen

Answer and Explanation

Correct Answer : A,D,E

A. Electrical cord on floor over a walkway:
An electrical cord on the floor in a walkway poses a significant tripping hazard. Clients may not notice the cord or may have difficulty stepping over it, increasing the risk of falls, particularly for individuals with impaired mobility or vision.

B. Demonstrates correct use of cane to ambulate:
Proper use of a cane improves balance and stability, reducing fall risk rather than contributing to it. Clients who demonstrate correct usage are actively minimizing their likelihood of falling.

C. Grab bar in the bathroom:
Grab bars provide added support and stability, particularly in areas prone to slips, such as bathrooms. Their presence is a preventive measure rather than a fall risk.

D. Diagnosis of Macular degeneration:
Macular degeneration impairs central vision, which can lead to difficulties in detecting obstacles and maintaining balance, increasing the client’s susceptibility to falls.

E. Throw rugs in kitchen:
Throw rugs are a well-documented fall hazard because they can slip, bunch up, or create uneven surfaces. They are particularly risky for older adults and those with mobility impairments.

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Correct Answer is A

Explanation

A) The client who has a nasogastric (NG) tube to suction:
A nasogastric (NG) tube that is used for suction can lead to the loss of gastric fluids, which are rich in potassium. Prolonged suctioning can cause the client to lose significant amounts of potassium, putting them at risk for hypokalemia. Potassium is an essential electrolyte that is vital for proper muscle and nerve function, and its loss can result in symptoms such as weakness, arrhythmias, and fatigue.

B) The client who has a chest tube to water seal:
A chest tube to water seal is used to drain air or fluid from the pleural space, typically following surgery or trauma. While chest tube drainage can lead to fluid loss, it is not directly associated with significant electrolyte imbalances like hypokalemia. The primary concern with chest tubes is fluid balance and preventing infection, but it does not specifically cause potassium loss unless there are other contributing factors, such as excessive diuresis or vomiting.

C) The client who has an indwelling urinary catheter to gravity drainage:
An indwelling urinary catheter primarily allows for the drainage of urine, and while it may contribute to fluid and electrolyte loss (especially if there is excessive urination or diuresis), it is not directly linked to hypokalemia unless the client is receiving medications (e.g., diuretics) that cause potassium loss through urine. The catheter itself does not significantly increase the risk of hypokalemia unless other factors are involved.

D) The client who has a tracheostomy tube attached to humidified oxygen:
A tracheostomy tube attached to humidified oxygen helps with respiratory support and does not directly affect potassium levels. The primary concern with tracheostomies is airway management, preventing infection, and ensuring proper oxygenation. It is not associated with electrolyte imbalances such as hypokalemia. However, if the client experiences issues such as excessive fluid loss through respiratory secretions or complications like infection, it could indirectly affect electrolyte levels, but it is not a direct cause of hypokalemia.

A. Hypokalemia B. Bleeding C. Bradycardia D. Seizures

Correct Answer is C

Explanation

A) Hypokalemia:
Hypokalemia (low potassium levels) is not a common adverse effect of labetalol. While some medications, such as diuretics, can lead to hypokalemia, labetalol does not typically affect potassium levels directly. Instead, labetalol's primary effects are on blood pressure and heart rate.

B) Bleeding:
Bleeding is not a typical adverse effect of labetalol. Labetalol is a beta blocker that works by blocking beta-adrenergic receptors, which lowers heart rate and blood pressure. It does not interfere with blood clotting or platelet function, so bleeding would not be a concern unless the patient is on other medications that affect coagulation (such as anticoagulants).

C) Bradycardia:
Bradycardia, or a slow heart rate, is a well-known and common adverse effect of beta blockers like labetalol. Labetalol works by blocking the beta-1 adrenergic receptors in the heart, which can reduce heart rate and lower blood pressure. In some individuals, this can result in bradycardia, which could lead to symptoms like dizziness, fatigue, and fainting.

D) Seizures:
Seizures are not a typical adverse effect of labetalol. Although central nervous system effects like dizziness or fatigue can occur due to the blood pressure-lowering effects, seizures are not commonly associated with this medication.

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

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