A nurse on the medical-surgical unit is conducting a fall risk assessment for four clients. The nurse should identify that which of the following clients is the greatest risk for a fall?

A client with diabetes mellitus who has a leg ulcer

An adolescent client who has a leg fracture and has been using crutches for the past 2 days

An older adult client who is confused and has urinary frequency

A client who is 1 day postoperative and has a nursing assistant helping him out of bed

Answer and Explanation

The Correct Answer is C

A. A client with a leg ulcer may have limited mobility but not necessarily the highest fall risk.
B. An adolescent using crutches is at some risk but typically has better balance and coordination than older adults.
C. An older adult who is confused and has urinary frequency is at the highest risk for falls due to impaired cognitive function and frequent need to get up to use the bathroom, which increases the likelihood of falls.
D. A postoperative client with assistance is less likely to fall compared to an unassisted confused older adult.

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Free Nursing Study Resources

Correct Answer is C

Explanation

A. Pediculicide lotions are used to treat lice, not ticks. They are not effective or appropriate for tick removal.
B. Twisting a tick during removal can cause the mouthparts to break off and remain embedded in the skin, increasing the risk of infection.
C. Grasping the tick as close to the skin as possible with fine-tipped tweezers allows for complete removal without squeezing the tick's body.
D. Using a hot ember or match tip can cause the tick to regurgitate into the skin, increasing the risk of disease transmission.

A. "Skip the morning dose if you do not have any symptoms." B. "Use this medication to relieve an acute attack." C. "Check your heart rate before each dose." D. "Inspect your mouth for lesions daily."

Correct Answer is D

Explanation

A. Fluticasone should be used regularly to prevent symptoms, not skipped based on symptom presence.
B. Fluticasone is a maintenance medication and is not effective for acute attacks.
C. Checking heart rate is not necessary with fluticasone use.
D. Inspecting the mouth for lesions daily is important to detect oral thrush, a potential side effect of inhaled corticosteroids.

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A nurse on the medical-surgical unit is conducting a fall risk assessment for four 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 is teaching a group of clients about tick-borne illnesses. Which of the following information should the nurse include in the teaching regarding ticks?

Correct Answer is C

Explanation

A nurse is teaching a client who has chronic obstructive pulmonary disease and is to start using fluticasone by MDI twice daily. Which of the following instructions should the nurse include?

Correct Answer is D

Explanation

A nurse is assisting with the admission of a client who is about to have elective surgery. The client tells the nurse she feels anxious. Which of the following responses should the nurse make?

A client who has Type 2 diabetes mellitus asks the nurse, "Why did I develop diabetes?" Which of the following responses should the nurse make?

A nurse is caring for a client who has a fractured ulna and a new prescription for cyclobenzaprine. Before administering, which of the following explanations should the nurse provide to explain the purpose of the medication?

A nurse is providing teaching to a client who has rheumatoid arthritis and a new prescription for methotrexate. Which of the following information should the nurse provide?

A nurse in the medical-surgical unit is assigning client care to a nurse who is floating from the PACU. The nurse should recognize that the float nurse is most qualified to care for which of the following clients?

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