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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Correct Answer is C

Explanation

A. Gentamicin administered over 1 hour is an appropriate method for this medication.
B. Injecting Demerol IM into the vastus lateralis is an acceptable site for adults.
C. Crushing bupropion XL (extended-release) tablets is contraindicated as it alters the drug's release mechanism, which can lead to a risk of overdose or ineffective treatment, requiring an incident report.
D. Using a 25-gauge ⅝ inch needle for heparin injection is an appropriate technique.

A. A Allergies B. B Circulation C. C Neurological status D. D Ventilation E. E Current medications F. F Exposure

Correct Answer is ["B","D","E"]

Explanation

A. Allergies
Allergies are important to know but are not part of the primary survey. The primary survey focuses on immediate life threats, such as airway, breathing, and circulation, rather than detailed background information.
B. Circulation
Assessment of circulation is critical in the primary survey to identify and manage life-threatening conditions such as shock or severe bleeding. It includes evaluating blood pressure, heart rate, and peripheral pulses to assess the effectiveness of the cardiovascular system.
C. Neurological status
While neurological status is important, it is part of a secondary survey rather than the primary survey. The primary survey focuses on immediate life-threatening conditions, while the neurological status is assessed more thoroughly in the secondary survey.
D. Ventilation
Assessing ventilation is a crucial part of the primary survey. This involves checking the client's breathing rate, depth, and effectiveness to ensure adequate oxygenation and addressing any immediate respiratory distress.
E. Current medications
Knowing current medications is important for overall care but is not part of the primary survey. The primary survey addresses life-threatening conditions rather than details of medication history.
F. Exposure
Exposure is part of the primary survey, ensuring that the client is completely exposed for a thorough assessment while protecting their privacy and warmth. It involves checking for hidden injuries and ensuring the client’s environment is safe.

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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 reviewing the medication administration records from the previous shift. Which of the following findings should indicate to the nurse a need for an incident report?

Correct Answer is C

Explanation

Exhibits The nurse inspects the airway. There is no visible trauma, and the airway appears to be patent. What other assessment items are included in the primary survey? Select all that apply.

Correct Answer is ["B","D","E"]

Explanation

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