Date/Time: 4/11/XXX 1402
Review the electronic health record. What is the client's risk for falls?
Low risk
Moderate risk
High risk
Very high risk
The Correct Answer is A
A. Low risk: Using the Fall Risk Screening Tool, the client scores 3 points for a fall in the past year, 0 points for age (56 years), 1 point for urinary frequency (as the client was walking to the bathroom when they tripped), 0 points for a steady gait, and 0 points for mental status. The total score is 4 points, which places the client in the low-risk category (0–5 points).
B. Moderate risk: Moderate risk requires 6–9 points. With a total score of 4, the client does not meet this threshold.
C. High risk: High risk is defined as 10 or more points, well above the client’s total score.
D. Very high risk: The tool does not include a “very high risk” category; the highest category is “high risk” (≥10 points).
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. All visitors should wear hair and shoe covers: Hair and shoe covers are not part of standard contact precautions for MRSA. Transmission occurs primarily through direct contact with contaminated surfaces or wounds rather than hair or footwear. Routine use of these items does not reduce MRSA spread.
B. All visitors should wear a gown and gloves: MRSA requires contact precautions to prevent transmission via hands and clothing. Gowns protect clothing from contamination, and gloves reduce direct contact with infectious material. This practice is consistent with infection prevention guidelines for multidrug-resistant organisms.
C. All visitors should wear goggles and gloves: Eye protection is reserved for situations with a risk of splashing or spraying of body fluids. MRSA wound care does not typically pose this risk during routine contact. Goggles are not routinely indicated.
D. All visitors should wear an N95 mask and gown: N95 respirators are used for airborne pathogens such as tuberculosis, not contact-spread organisms like MRSA. Respiratory protection is unnecessary unless aerosol-generating procedures are involved.
Correct Answer is B
Explanation
A. Skip oral care due to unconsciousness: Oral care is essential for unconscious clients to prevent mucosal breakdown, infection, and ventilator-associated complications. Skipping oral care increases the risk of bacterial overgrowth and aspiration. Consciousness level does not eliminate the need for hygiene.
B. Use warm water and soap for bathing: Warm water with mild soap promotes comfort, removes dirt and oils, and maintains skin integrity. Maintaining appropriate water temperature prevents hypothermia and enhances patient tolerance during hygiene procedures.
C. Perform hygiene without donning gloves: Gloves are necessary to protect both the client and nurse from pathogens present in body fluids or secretions. Performing hygiene without gloves increases the risk of infection transmission. Standard precautions must always be followed.
D. Utilize unused linens from another client: Using linens from another client violates infection control principles and can transmit pathogens. Each client requires their own clean linens to prevent cross-contamination.
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