Which assessment data reflects the need for the nurse to include the problem, "Risk for falls" in a client's plan of care?

Reference Range:

Hemoglobin [14 to 18 g/dL (140 to 180 g/L)]

Recent serum hemoglobin level of 16 g/dL (160 g/L).

Opioid analgesic received one hour ago.

Expressed feelings of depression.

Stooped posture with a steady gait.

Answer and Explanation

The Correct Answer is B

A.   A serum hemoglobin level of 16 g/dL (160 g/L) is within the normal reference range for adults (14 to 18 g/dL). Hemoglobin levels that are within the normal range generally do not indicate a direct risk for falls. Low hemoglobin (anemia) could potentially increase fall risk due to fatigue or dizziness, but a normal level is not a risk factor for falls.
B.   Opioid analgesics are known to have side effects such as sedation, dizziness, and impaired motor coordination, which can increase the risk of falls. The recent administration of opioids makes this a significant factor in assessing fall risk, as the client may still be experiencing side effects from the medication that could impair their balance or cognitive function.
C.   Depression can contribute to fall risk in several ways, including reduced motivation to engage in activities, decreased physical strength, and impaired attention. However, while important to address, depression alone is not as immediate or direct a risk factor for falls compared to factors like recent medication side effects or actual physical impairments.
D.   Stooped posture may be indicative of issues such as musculoskeletal problems or balance difficulties. However, if the client has a steady gait, it suggests that despite the stooped posture, their current ability to walk is stable. The stooped posture alone might increase fall risk over time, but it is not as directly related to the immediate risk of falls as recent medication effects.

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Correct Answer is A

Explanation

A. The Z-track technique helps to prevent medication from leaking into the subcutaneous tissue and minimizes irritation by sealing the medication in the muscle. This is especially important for medications that are known to cause irritation or staining, such as iron supplements or some antipsychotics
B. The length of the needle is not directly related to the use of the Z-track technique. The Z-track method is used to minimize irritation and ensure that the medication is deposited in the muscle rather than leaking into the subcutaneous tissue.
C. The reason for using the Z-track technique is related to preventing irritation and ensuring proper medication delivery, rather than simply following a prescription.
D. The volume of medication is not the primary reason for using the Z-track technique. While the Z-track method can be used for administering larger volumes of medication, the technique's primary purpose is to prevent leakage and reduce tissue irritation.

A. Protein. B. Hemoglobin. C. White blood cell count D. Sodium.

Correct Answer is D

Explanation

A. While protein levels are important in assessing overall nutritional status and can indicate conditions like malnutrition or liver disease, they are not the primary focus in the context of fever, dry mucous membranes, and skin turgor changes.
B. Hemoglobin levels are crucial for assessing anemia and overall oxygen-carrying capacity of the blood. Although dehydration can potentially concentrate hemoglobin levels, it is not the primary laboratory value to monitor in the context of the acute symptoms
C. The white blood cell count is important for diagnosing infections and understanding the body's response to illness. However, in this scenario, the primary concern is dehydration, which is not directly measured by WBC count. While an elevated WBC could indicate an infection contributing to the fever, it is not the primary laboratory value to monitor for fluid and electrolyte imbalances.
D. Sodium is a key electrolyte that can be significantly affected by dehydration. Dry mucous membranes, inelastic skin turgor, and a fever suggest potential fluid loss and dehydration, which can lead to imbalances in sodium levels. Monitoring sodium levels is crucial because dehydration often results in elevated sodium concentrations (hypernatremia), which can have serious implications for the client’s health.

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Which assessment data reflects the need for the nurse to include the problem, "Risk for falls" in a client's plan of care? Reference Range: Hemoglobin [14 to 18 g/dL (140 to 180 g/L)]

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Naxlex Comprehensive Predictor Exams

The nurse is teaching another nurse about the administration of medication using the Z track technique. Which is the primary reason for using a Z track technique to administer a medication?

Correct Answer is A

Explanation

An older adult client's skin feels warm and the client has a temperature of 101.2° F (38.4° C). The nurse further assesses that the client has a reddened tongue, dry mucous membranes, and inelastic skin turgor. Which serum laboratory value should the nurse monitor most closely?

Correct Answer is D

Explanation

Which assessment data reflects the need for the nurse to include the problem, "Risk for falls" in a client's plan of care? Reference Range: Hemoglobin [14 to 18 g/dL (140 to 180 g/L)]

The nurse attaches a pulse oximeter to a client's finger and obtains an oxygen saturation reading of 91%. Which assessment finding most likely contributes to this reading?

The nurse observes that a client on a clear liquid diet has a cup of coffee on the breakfast tray. Which action should the nurse implement?

The nurse is demonstrating three-point gait crutch walking to an older adult man who broke his foot while playing soccer with his grandchildren. Which behavior indicates that the client understands proper crutch walking?

A client is admitted with possible pneumonia. When entering the room, the nurse observes the client's face as seen in the picture. Which prescription should the nurse implement first?

Which assessment data reflects the need for the nurse to include the problem, "Risk for falls" in a client's plan of care?

Reference Range:

Hemoglobin [14 to 18 g/dL (140 to 180 g/L)]