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. Clients receiving immune suppressant therapy, such as those undergoing treatment for cancer, are at a significantly increased risk for healthcare-associated infections. Immune suppressants weaken the body's ability to mount an effective immune response, making individuals more susceptible to infections.
B. Hyperemia, or increased blood flow to a particular area, can be a sign of an acute local infection. While it indicates the presence of infection, the hyperemia itself does not increase the risk of developing a new or additional healthcare-associated infection.
C. Weight loss, especially if associated with dietary changes, may affect overall health and nutritional status, potentially impairing wound healing and immune function. However, it is not as directly linked to an increased risk of HAIs as immune suppression or invasive procedures.
D. Receiving vaccinations generally aims to enhance immunity and protect against specific infections. Immunizations can help prevent infections but do not increase the risk of healthcare-associated infections. This action is preventive rather than a risk factor for HAIs.

A. Add the second portion of the feeding before the syringe is completely empty. B. Use 25 mL of water between the two portions of the feeding to flush the GT. C. Raise the syringe barrel higher to increase the flow rate of the bolus feeding. D. Flush the tube with 50 mL of water between the two portions of the feeding.

Correct Answer is D

Explanation

A. This instruction is not recommended because adding the second portion of the feeding before the syringe is empty can lead to inconsistent feeding rates and potential complications, such as overloading the stomach with too much formula at once.
B. Flushing the GT with water between portions of feeding is a good practice to prevent clogging and to ensure that all formula is delivered. However, 25 mL of water is generally not enough; standard practice typically involves using 30 to 60 mL of water for effective flushing. This option is close but not as specific as the recommended volume.
C. Raising the syringe barrel can increase the flow rate of the feeding, but this approach should be used with caution. Rapid flow can cause gastrointestinal discomfort or cramping. The primary focus should be on ensuring proper flushing and administration rather than manipulating the flow rate in this way.
D. This option is the best practice because flushing the GT with 50 mL of water between portions of the feeding helps to clear any remaining formula from the tube and prevents clogging. Proper flushing also helps ensure that the entire dose of formula is delivered and maintains tube patency.

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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 identifies the hospitalized client in which situation as being at highest risk for the development of a healthcare associated infection (HAI)?

Correct Answer is A

Explanation

Correct Answer is D

Explanation

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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)]