all of the following factors may contribute to client falls except

NCLEX-RN

Safe and Effective Care Environment NCLEX RN Questions

1. All of the following factors may contribute to client falls EXCEPT:

A. Contact dermatitis
B. Urinary frequency
C. Decreased visual acuity
D. Confusion

Correct answer: A

Rationale: Client falls can result from various factors, both intrinsic and extrinsic. Intrinsic factors include health conditions like urinary frequency, which increases the need for bathroom visits, decreased visual acuity, and confusion. These factors can directly contribute to an increased risk of falls. However, contact dermatitis does not directly lead to falls. Contact dermatitis is a skin condition caused by contact with irritants or allergens and does not inherently predispose individuals to falling. Therefore, among the given options, contact dermatitis is the only factor that is not directly associated with an increased risk of falls.

2. During a heritage assessment, which question is most appropriate for the nurse to ask?

A. "Do you smoke?"?
B. "What is your religion?"?
C. "Do you have a history of heart disease?"?
D. "How many years have you lived in the United States?"?

Correct answer: D

Rationale: During a heritage assessment, it is crucial for the nurse to ask questions related to a person's country of ancestry, years in the United States, cultural practices, beliefs, and values. By asking about the number of years lived in the United States, the nurse can gain insights into the individual's cultural background and heritage. Options B, C, and A are not directly related to assessing heritage. Asking about religion only addresses one aspect of heritage, while smoking history and health history do not provide a comprehensive view of a person's heritage.

3. What are Korotkoff sounds?

A. Sounds noted during diastole.
B. The result of the vibration of blood against artery walls while blood pressure readings are being taken.
C. Sounds only noted by skilled cardiologists.
D. Distinct sounds which are classified into 6 phases.

Correct answer: B

Rationale: Korotkoff sounds are the sounds that occur when blood flows in an artery that has been temporarily compressed during a blood pressure measurement. These sounds result from the vibration of blood against the artery walls as the pressure cuff is released. There are five distinct phases of Korotkoff sounds, which healthcare providers are trained to identify during blood pressure assessment. The correct answer, choice B, accurately describes the nature of Korotkoff sounds and how they are generated. Choices A, C, and D are incorrect because Korotkoff sounds are not specific to diastole, not limited to skilled cardiologists, and categorized into five phases, not six.

4. A patient in a clinic has been diagnosed with hepatitis A. What is the most likely route of transmission?

A. Sexual contact with an infected partner
B. Contaminated food
C. Blood transfusion
D. Illegal drug use

Correct answer: B

Rationale: The correct answer is contaminated food. Hepatitis A is primarily transmitted through the fecal-oral route, often through the ingestion of contaminated food or water. It is caused by the Hepatitis A virus (HAV), which is a single-stranded, positive-sense RNA virus. Sexual contact with an infected partner is more commonly associated with hepatitis B and C. Blood transfusion is a potential route for hepatitis B and C transmission due to bloodborne pathogens. Illegal drug use, particularly involving shared needles, is a common route for hepatitis C transmission.

5. Your patient had a stroke, or CVA, five years ago. The resident still has right-sided weakness. You are ready to transfer the resident from the bed to the wheelchair. The wheelchair should be positioned at the _____________.

A. head of the bed on the patient's right side
B. head of the bed on the patient's left side
C. bottom of the bed on the patient's right side
D. bottom of the bed on the patient's left side

Correct answer: B

Rationale: The wheelchair should be positioned at the head of the bed on the resident's left side. This positioning allows the resident to use their stronger left side to assist with the transfer, compensating for the right-sided weakness. Placing the wheelchair at the head of the bed on the patient's right side (Choice A) would not utilize the stronger left side, which is crucial for the transfer. Similarly, positioning the wheelchair at the bottom of the bed on either side (Choices C and D) would not facilitate optimal assistance from the resident's stronger side during the transfer process.