Exam Review
Conclusion
Total Questions : 10
Showing 10 questions, Sign in for moreThe nurse is caring for an older adult client who is at risk for falls. Which action by the nurse is most appropriate?
No explanation
A nurse is caring for a client at risk for falls. Which intervention is most important for fall prevention?
Explanation
d. Ensuring the client has adequate lighting in the room.
Answer: b. Encouraging the client to use the call bell for assistance. Explanation: Encouraging the client to use the call bell for assistance is the most important intervention for fall prevention. It promotes the client's involvement in their own safety and ensures that help is readily available when needed.
Incorrect choices: a. Placing a sign on the client's room door indicating fall risk is a helpful visual reminder, but it does not actively prevent falls. c. Providing a nonskid mat on the floor beside the client's bed can reduce the risk of slipping but does not address other factors that contribute to falls. d. Ensuring the client has adequate lighting in the room is important for preventing falls, but it is not the most critical intervention. The client's ability to seek assistance when needed is more crucial.
The nurse is completing a fall risk assessment for a client. Which factor places the client at the highest risk for falls?
Explanation
Answer: c. History of previous falls. Explanation: A history of previous falls is a significant risk factor for future falls. Clients who have fallen before are more likely to fall again, making it a high-risk factor to consider in fall prevention strategies.
Incorrect choices: a. Age over 65 years is a general risk factor for falls but does not provide as much predictive value as a history of previous falls. b. Use of anticoagulant medications increases the risk of bleeding but does not necessarily indicate a higher risk for falls. d. Presence of sensory deficits, such as visual or auditory impairments, can contribute to fall risk but may not be the highest-risk factor compared to a history of previous falls.
The nurse is caring for a client on a medical-surgical unit. Which intervention is most important for preventing falls in this client population?
Explanation
Answer: c. Implementing hourly rounding to assess the client's needs. Explanation: Implementing hourlyrounding to assess the client's needs is the most important intervention for preventing falls in a medical-surgical unit. Regular rounding allows the nurse to monitor the client's condition, address any immediate needs, and provide assistance with mobility or other activities, reducing the risk of falls.
Incorrect choices: a. Providing a bedside commode for toileting needs is important for promoting safe toileting, but it does not address the overall risk of falls. b. Placing the client in a private room near the nurses' station may enhance surveillance, but it does not actively prevent falls. d. Educating the client on proper use of assistive devices is essential, but it is not the most critical intervention for fall prevention in the medical-surgical unit setting.
The nurse is caring for a client who is at risk for falls. Which action by the nurse is most appropriate to prevent falls?
Explanation
Answer: a. Keeping the client's bed in the lowest position. Explanation: Keeping the client's bed in the lowest position is the most appropriate action to prevent falls. A low bed height reduces the risk of injury if the client accidentally falls out of bed.
Incorrect choices: b. Using bed rails to restrict the client's movement is not recommended as it can increase the risk of entrapment or injury. Bed rails should be used judiciously and with caution. c. Providing the client with nonskid footwear is important for promoting stability and preventing slips and falls, but it is not the most crucial intervention in this scenario. d. Administering sedative medications at bedtime increases the risk of falls by affecting the client's balance and alertness. Sedatives should be used sparingly and only when necessary.
he nurse is caring for a client who experienced a fall. Which action by the nurse is most appropriate
Explanation
Answer: c. Implementing fall prevention interventions for the client. Explanation: After a fall, the most appropriate action for the nurse is to implement fall prevention interventions for the client. This includes reassessing the client's risk factors, modifying the environment, and providing necessary support and assistance to prevent future falls.
Incorrect choices: a. Documenting the fall incident in the client's medical record is an essential step but should follow the immediate implementation of fall prevention interventions. b. Conducting a comprehensive fall risk assessment is important, but it should be done as part of the ongoing care and assessment rather than immediately after a fall. d. Reporting the fall to the unit manager is necessary for organizational reporting purposes, but it does not directly address the client's immediate safety needs.
The nurse is caring for a client with a history of falls. Which statement by the client indicates a need for further education on fall prevention?
Explanation
Answer: a. "I will make sure to wear my eyeglasses all the time." Explanation: The statement "I will make sure to wear my eyeglasses all the time" indicates a need for further education on fall prevention. While wearing eyeglasses can improve vision, it is not adirect fall prevention measure. It is important for the client to address other risk factors such as environmental hazards, balance, and mobility.
Incorrect choices: b. "I will use the handrails when going up and down the stairs." This statement demonstrates an understanding of using handrails for support and stability while navigating stairs, which is an appropriate fall prevention measure. c. "I will ask for help when I need to use the bathroom at night." This statement reflects the client's awareness of the need to seek assistance when necessary, reducing the risk of falls during nighttime bathroom visits. d. "I will keep my room well-lit during the day and night." This statement indicates an understanding of the importance of adequate lighting to enhance visibility and prevent falls in the client's room.
The nurse is caring for an older adult client who is at risk for falls. Which intervention is most appropriate to address the client's specific fall risk
Explanation
the client with a bed alarm system. d. Recommending the use of a cane or walker.
Answer: d. Recommending the use of a cane or walker. Explanation: Recommending the use of a cane or walker is the most appropriate intervention for an older adult client at risk for falls. Assistive devices can provide additional support and stability, helping to maintain balance and reduce the risk of falls.
Incorrect choices: a. Implementing a toileting schedule for the client is important but may not directly address the client's specific fall risk. b. Assessing the client's orthostatic blood pressure is essential for assessing orthostatic hypotension but may not be the most appropriate intervention for addressing fall risk in this scenario. c. Providing the client with a bed alarm system can help alert the nursing staff when the client is attempting to leave the bed, but it does not directly address the client's balance and stability needs.
The nurse is caring for a client with a recent history of falls. Which intervention is most important for the nurse to implement?
Explanation
Answer: a. Removing tripping hazards from the client's environment. Explanation: Removing tripping hazards from the client's environment is the most important intervention for preventing falls. It helps create a safe and hazard-free environment, reducing the risk of accidental falls.
Incorrect choices: b. Providing the client with nonskid footwear is important for promoting stability and preventing slips and falls but may not address all potential fall risks. c. Educating the client on the correct use of handrails is essential, but it may not be the most critical intervention compared to removing environmental hazards. d. Assisting the client with toileting and ambulation is important, but it focuses on direct assistance rather than eliminating hazards from the environment.
The nurse is providing discharge education to a client on fall prevention. Which statement by the client indicates understanding of the instructions
Explanation
Answer: a. "I will use a nightlight in my bedroom and bathroom." Explanation: The statement "I will use a nightlight in my bedroom and bathroom" indicates understanding of the need for adequate lighting to prevent falls during nighttime activities.
Incorrect choices: b. "I will make sure to rush to answer thephone." This statement demonstrates a misunderstanding of the importance of prioritizing safety over rushing to answer the phone, which may increase the risk of falls. c. "I will keep my medication bottles on the kitchen counter." This statement suggests a potential hazard of leaving medication bottles on the counter, which can increase the risk of falls due to clutter and potential spills. d. "I will wear socks with a smooth sole for better comfort." This statement indicates a lack of understanding of the importance of wearing nonskid footwear to maintain traction and prevent slips and falls. Smooth-soled socks may increase the risk of slipping on smooth surfaces.
Sign Up or Login to view all the 10 Questions on this Exam
Join over 100,000+ nursing students using Nursingprepexams’s science-backend flashcards, practice tests and expert solutions to improve their grades and reach their goals.
Sign Up Now
