The practical nurse (PN) reviews the history of an older adult who is newly admitted to a long term care facility.
Which factor in the resident's history should the PN consider the most likely to increase the client's risk for falls?
Ankle ulcer that is healing slowly.
History of alcohol abuse and cigarete smoking.
Recent weight gain of twenty pounds.
Newly prescribed antihypertensive medication.
The Correct Answer is D
This is the factor that the PN should consider the most likely to increase the client's risk for falls because it can cause orthostatic hypotension, dizziness, or fainting, especially when the client changes position or gets up from bed or a chair. The PN should monitor the client's blood pressure and pulse before and after administering the medication and assist the client with ambulation and transfers.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","C","E"]
Explanation
Choice A rationale:
Obtaining a post-voided residual (PVR) volume is a non-invasive procedure that can be safely delegated to the unlicensed assistive personnel (UAP) to measure the amount of urine left in the bladder after urination.
Choice B rationale:
Teaching the client with fluid restrictions how to measure urine output requires specialized knowledge and is best performed by the practical nurse (PN).
Choice C rationale:
Emptying the bedside drainage unit for a client with an indwelling urinary catheter is a task that can be delegated to the UAP as it involves routine drainage and does not require advanced nursing skills.
Choice D rationale:
Irrigating an indwelling urinary catheter for a client with bladder suspension is a sterile procedure that requires nursing expertise, so it should not be assigned to the unlicensed assistive personnel.
Choice E rationale:
Transporting a urine culture sample to the laboratory is a non-complex task that can be safely delegated to the UAP to ensure timely and efficient delivery.
Correct Answer is A
Explanation
"I will be back in 30 minutes to help you get out of bed and walk around the room today.”.
Choice B rationale:
Telling the client that she must ambulate to avoid complications (Choice B) may be true, but it comes across as authoritarian and may further upset the client. It is essential to address the client's feelings of anger and approach the situation with empathy and understanding.
Choice C rationale:
Acknowledging the client's anger about the pain of ambulation (Choice C) is a good start, but it is not enough. The nurse should follow up with a plan to assist and encourage the client to walk later, promoting collaboration in the healing process.
Choice D rationale:
Informing the client about specific instructions to ambulate (Choice D) is important, but the response lacks empathy and fails to address the client's feelings. The nurse needs to consider the client's mental disability and approach the situation with sensitivity.
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