which of the following statements from a client may indicate that they are at a higher risk for a fall

NCLEX-PN

Safe and Effective Care Environment Nclex PN Questions

1. Which of the following statements from a client may indicate that they are at a higher risk for a fall?

A. "I would like to get out of bed but would like to put on my non-skid socks first."?
B. "Can you make sure the two bedrails are raised before leaving the room?"?
C. "I think I'm ready to walk a longer distance with the cane today."?
D. "I need to get out of bed to go to the bathroom now. I cannot find my glasses but cannot wait."?

Correct answer: D

Rationale: The correct answer is 'I need to get out of bed to go to the bathroom now. I cannot find my glasses but cannot wait.' This statement indicates that the client is in a hurry and unable to find their glasses, which could increase the risk of a fall due to impaired vision. Choice A about putting on non-skid socks shows the client's awareness of fall prevention, reducing the risk. Choice B demonstrates the client's request for bedrails to be raised, which is a safety measure, reducing the risk as well. Choice C suggests the client's readiness to walk a longer distance with a cane, indicating progress in mobility but not necessarily a higher fall risk.

2. While working the 11 p.m. to 7 a.m. shift at the long-term care unit, the nurse gathers the nursing staff to listen to the 3 to 11 p.m. intershift report. The nurse notes that a staff member has an odor of alcohol on her breath, slurred speech, and an unsteady gait, suspecting alcohol intoxication. What is the most appropriate action for the nurse to take?

A. Contact the nursing supervisor.
B. Tell the staff member that she is not allowed to administer medications.
C. Ask the staff member how much alcohol she has consumed.
D. Ask the staff member to rest in the nurses' lounge until the effects of the alcohol wear off.

Correct answer: A

Rationale: When a staff member reports to work showing signs of alcohol intoxication, the nurse should objectively note the symptoms and ask a second person to confirm these observations. It is crucial to contact the nursing supervisor immediately. An odor of alcohol, slurred speech, unsteady gait, and errors in judgment are indicators of intoxication, posing a risk to client safety. The staff member should be removed from the client care area. Detailed documentation of the incident is essential, including observations, actions taken, future plans, and the staff member's signature and date on the recorded incident memo. If the staff member refuses to sign, this should be noted by the nurse and a witness. Asking the staff member to rest in the nurses' lounge or restricting medication administration does not ensure client safety, as the staff member could still jeopardize it. Inquiring about the amount of alcohol consumed is confrontational and not relevant to the immediate need of ensuring safety.

3. A health care provider writes a medication prescription in a client's record. While transcribing the prescription, the nurse notes that the prescribed dose is three times higher than the recommended dose. The nurse calls the health care provider, who states that this is the dose that the client takes at home and that it is acceptable for this client's condition. What is the appropriate action for the nurse to take?

A. Verifying the prescribed dose with the client before administering the medication
B. Contacting the nursing supervisor
C. Asking the nurse assigned to care for the client to administer the medication
D. Continuing to transcribe the prescription

Correct answer: B

Rationale: In this scenario, the nurse has identified a significant discrepancy between the prescribed dose and the recommended dose. While the health care provider has justified the higher dose based on the client's home regimen, the nurse's primary responsibility is to ensure patient safety. If a nurse has concerns about a prescription being incorrect or potentially harmful, they should seek further clarification from the health care provider. Since the nurse still believes the dose is inappropriate after discussing with the health care provider, the next appropriate action is to contact the nursing supervisor. Continuing to transcribe the prescription without addressing the concern could jeopardize the client's safety. Asking another nurse to administer the medication without proper resolution of the dosage concern would also pose a risk to the client. While verifying the prescribed dose with the client is important, in this situation, the nurse should first escalate the issue to the nursing supervisor to ensure appropriate actions are taken.

4. Which situation is an example of the use of evidence-based practice in the delivery of client care?

A. Encouraging a client who has had a stroke to consume thickened liquids and soft foods
B. Picking up a dislodged radiation implant with long-handled forceps and placing it in a lead container to minimize radiation exposure
C. Pouring 1 to 2 mL of sterile solution that will be used for wound cleansing into a plastic-lined waste receptacle before pouring the solution into a sterile basin
D. Blowing on a fingerstick site to dry it after cleaning the site with an alcohol swab

Correct answer: C

Rationale: Evidence-based practice is an approach that integrates client preferences, clinical expertise, and the best research evidence to deliver quality care. Pouring sterile solution into a plastic-lined waste receptacle before using it for wound cleansing reflects evidence-based practice by preventing the entrance of harmful bacteria into the wound. Option A is incorrect because encouraging a stroke client to consume thickened liquids and soft foods is appropriate, not thin liquids and foods that pose a choking risk. Option B is incorrect as picking up a radiation implant with long-handled forceps to minimize radiation exposure is a safety measure, not evidence-based practice. Option D is incorrect because blowing on a fingerstick site after cleaning can recontaminate the site, which goes against best practices in infection control.

5. How often should physical restraints be released?

A. Every 2 hours
B. Between 1 and 3 hours
C. Every 30 minutes
D. At least every 4 hours

Correct answer: A

Rationale: The correct answer is to release physical restraints every 2 hours. Releasing restraints every 2 hours helps prevent complications associated with prolonged immobilization. Releasing restraints every 30 minutes (choice C) may be too frequent and disruptive to the client's care. Releasing restraints between 1 and 3 hours (choice B) introduces variability that could lead to inconsistencies in care. Releasing restraints at least every 4 hours (choice D) does not adhere to the recommended frequency of every 2 hours.