While the nurse is assessing an older client's fall risk, the client reports living at home alone and never falling. Which action should the nurse take?

Continue to obtain client data needed to complete the fall risk survey.

Inform the client that falls occur more often in the hospital than at home.

Record a minimal risk for falls, documenting the client's statement.

Place the client on a high fall risk protocol because of advanced age.

Answer and Explanation

The Correct Answer is A

Choice A reason: Completing the fall risk survey provides a comprehensive assessment of the client's fall risk, considering all factors.

Choice B reason: Informing the client that falls occur more often in the hospital does not complete the assessment.

Choice C reason: Recording a minimal risk based solely on the client's statement may not accurately reflect the true fall risk.

Choice D reason: Placing the client on high fall risk protocol based on age alone is not appropriate without a complete assessment.

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Correct Answer is A

Explanation

Choice A reason: Administering cefazolin, an antibiotic, is a priority to prevent or treat potential infections in the immediate postoperative period.

Choice B reason: Completing a CBC in the morning is important for ongoing assessment but is not an immediate priority.

Choice C reason: Advancing the diet as tolerated is important but can be done after ensuring infection prevention.

Choice D reason: Straight catheterization is necessary if the client is unable to void but is not the immediate priority compared to preventing infection.

A. A listing of African-American women who live in the community. B. Morbidity data for breast cancer in women of all races. C. Technical assistance to produce a video on breast self-examination. D. Participation of community leaders in planning the program.

Correct Answer is D

Explanation

Choice A reason: A listing of African-American women in the community may help identify the target audience but is not as crucial as engaging the community leaders.

Choice B reason: Morbidity data for breast cancer in women of all races provides background information but does not directly address the specific needs of African-American women.

Choice C reason: Technical assistance to produce a video is useful but secondary to involving the community in the planning process.

Choice D reason: Participation of community leaders is vital as they can provide insights into cultural and social factors that influence health behaviors, ensuring the program is culturally relevant and effective.

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While the nurse is assessing an older client's fall risk, the client reports living at home alone and never falling. Which action should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is admitting a client from the postanesthesia care unit (PACU) to the postoperative surgical care unit. Which prescription should the nurse implement first?

Correct Answer is A

Explanation

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Correct Answer is D

Explanation

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