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 C
Explanation
The correct answer is Choice C:
Gather the procedure tray and equipment. Choice A rationale:
Placing the client in an orthopneic position (sitting upright and leaning forward) is not necessary for a thoracentesis procedure. The position may be uncomfortable for the client and does not facilitate the procedure.
Choice B rationale:
Keeping the client NPO (nothing by mouth) and encouraging them to void before the procedure is not directly relevant to a thoracentesis. NPO status might be indicated for other procedures requiring anesthesia but not for a bedside thoracentesis.
Choice C rationale:
This is the correct choice. The PN should prepare by gathering the procedure tray and equipment before the healthcare provider arrives to perform the thoracentesis. This ensures that all necessary items are readily available for the procedure.
Choice D rationale:
Cleansing the site and covering it with a sterile towel is a task usually performed by the healthcare provider who will be performing the thoracentesis. The PN's role is to prepare the necessary equipment and assist the provider during the procedure.
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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