Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
A nurse on the medical-surgical unit is conducting a fall risk assessment for four clients. The nurse should identify that which of the following clients is the greatest risk for a fall?
A. A client with diabetes mellitus who has a leg ulcer
A client with a leg ulcer may have limited mobility but not necessarily the highest fall risk.
B. An adolescent client who has a leg fracture and has been using crutches for the past 2 days
An adolescent using crutches is at some risk but typically has better balance and coordination than older adults.
C. An older adult client who is confused and has urinary frequency
An older adult who is confused and has urinary frequency is at the highest risk for falls due to impaired cognitive function and frequent need to get up to use the bathroom, which increases the likelihood of falls.
D. A client who is 1 day postoperative and has a nursing assistant helping him out of bed
A postoperative client with assistance is less likely to fall compared to an unassisted confused older adult.
This question is an excerpt from Nurse Dive's nursing test bank - Ati med surg pharm comprehensive proctored exam. Take the full exam now
Full Explanation
A. A client with a leg ulcer may have limited mobility but not necessarily the highest fall risk.
B. An adolescent using crutches is at some risk but typically has better balance and coordination than older adults.
C. An older adult who is confused and has urinary frequency is at the highest risk for falls due to impaired cognitive function and frequent need to get up to use the bathroom, which increases the likelihood of falls.
D. A postoperative client with assistance is less likely to fall compared to an unassisted confused older adult.
Similar Questions
A nurse in the medical-surgical unit is assigning client care to a nurse who is floating from the PACU. The nurse should recognize that the float nurse is most qualified to care for which of the following clients?
A. A client who is being discharged to a long-term care facility
The float nurse may not be familiar with discharge planning specific to long-term care facilities.
B. A client who is postoperative following a lobectomy and has a chest tube
A nurse from the PACU is highly experienced with postoperative care and monitoring of clients with chest tubes, making this the most appropriate assignment.
C. A client who needs teaching about insulin self-administration
Teaching about insulin self-administration requires specific education techniques which the float nurse might not be most familiar with.
D. A client who needs teaching prior to initiating cardiac rehabilitation activities
Teaching for cardiac rehabilitation involves specialized knowledge that might be outside the float nurse’s expertise.
Full Explanation
Rationale:
A. The float nurse may not be familiar with discharge planning specific to long-term care facilities.
B. A nurse from the PACU is highly experienced with postoperative care and monitoring of clients with chest tubes, making this the most appropriate assignment.
C. Teaching about insulin self-administration requires specific education techniques which the float nurse might not be most familiar with.
D. Teaching for cardiac rehabilitation involves specialized knowledge that might be outside the float nurse’s expertise.
A nurse is caring for the client who has Ménière's disease and asks if he is allowed to ambulate independently. Which of the following responses should the nurse make?
A. "Yes, you are free to move around as you wish."
Allowing free movement could increase the risk of falls due to dizziness.
B. "We will have to get a prescription from your provider.
While involving the provider is important, immediate safety measures should be communicated directly.
C. "No, you are on strict bedrest and must not be up."
Strict bedrest is not typically necessary, and movement can help prevent complications like blood clots.
D. "Please ring for assistance when you wish to get out of bed."
Assisting the client when they wish to get out of bed ensures safety by preventing falls, which are a significant risk for those with Ménière's disease due to vertigo.
Full Explanation
A. Allowing free movement could increase the risk of falls due to dizziness.
B. While involving the provider is important, immediate safety measures should be communicated directly.
C. Strict bedrest is not typically necessary, and movement can help prevent complications like blood clots.
D. Assisting the client when they wish to get out of bed ensures safety by preventing falls, which are a significant risk for those with Ménière's disease due to vertigo.
A nurse is planning care for a client who has immunosuppression following chemotherapy. Which of the following interventions should the nurse include in the plan of care?
A. Take the client's temperature once per shift.
Temperature should be monitored more frequently in immunosuppressed clients to detect early signs of infection.
B. Provide the client with fresh fruit to avoid constipation.
Fresh fruit can introduce bacteria or fungi, increasing infection risk in immunosuppressed clients.
C. Limit the number of health care workers entering the room.
Limiting the number of health care workers entering the room helps reduce the risk of infection by minimizing exposure to potential pathogens.
D. Insert an indwelling catheter to monitor sediment in the urine.
An indwelling catheter can increase the risk of infection and should be avoided unless absolutely necessary.
Full Explanation
Rationale:
A. Temperature should be monitored more frequently in immunosuppressed clients to detect early signs of infection.
B. Fresh fruit can introduce bacteria or fungi, increasing infection risk in immunosuppressed clients.
C. Limiting the number of health care workers entering the room helps reduce the risk of infection by minimizing exposure to potential pathogens.
D. An indwelling catheter can increase the risk of infection and should be avoided unless absolutely necessary.