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 C

Explanation

Choice A reason: Confirming the continuous passive motion device is intact is important but secondary to assessing the source of the drainage.

Choice B reason: Withholding the next dose of low molecular weight heparin should only be done based on a healthcare provider's order after assessing the situation.

Choice C reason: Determining if the wound drainage device is functioning correctly is essential to manage the excessive drainage and ensure that there is no blockage or malfunction.

Choice D reason: Monitoring the client's WBC count is important for detecting infection but is not the immediate action required for managing active drainage.

A. Hold the infant with head and shoulders slightly elevated. B. Use the syringe plunger to push formula at a rate of 5 ml/minute. C. Microwave refrigerated formula to room temperature. D. Measure and discard residual gastric contents before feeding.

Correct Answer is A

Explanation

Choice A reason: Holding the infant with head and shoulders slightly elevated helps prevent aspiration during feeding.

Choice B reason: Using the syringe plunger to push formula can increase the risk of aspiration and is not recommended.

Choice C reason: Microwaving formula can create hot spots and is not a safe method to warm formula.

Choice D reason: Measuring and discarding residual gastric contents is not typically recommended for routine feeding and can lead to improper assessment.

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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

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Explanation

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