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 B
Explanation
PVCs are abnormal heartbeats that occur when a ventricle contracts earlier than expected. They can indicate electrolyte imbalance, such as hypokalemia, which can result from NG suctioning. The PN should report this finding to the healthcare provider, as it may require treatment or adjustment of the suctioning.
The other options are not correct because:
A. Hyperactive bowel sounds on assessment may indicate increased peristalsis or bowel obstruction, but they are not related to the client's symptoms or NG suctioning.
C. Hypoactive bowel sounds on assessment may indicate decreased peristalsis or ileus, which are expected after bowel surgery and do not require immediate intervention.
D. Regular heart rate of 100 beats per minute on telemetry may indicate tachycardia, which can have various causes, but it is not as concerning as PVCs in this context.
Correct Answer is A
Explanation
The correct answer is choicea. Teach the client to use a straw when taking the medication to reduce further tooth staining.
Choice A rationale:
Using a straw when taking liquid iron preparations helps minimize contact with the teeth, thereby reducing the risk of staining.
Choice B rationale:
While tooth discoloration can indicate that the iron is being absorbed, it is not a desired effect and should be managed to prevent cosmetic concerns.
Choice C rationale:
Assessing for mouth or gum pain and difficulty swallowing is important but not directly related to the issue of tooth staining.
Choice D rationale:
Advising the client to withhold doses without consulting a healthcare provider could lead to non-compliance and inadequate treatment of iron deficiency.
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