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ISPN考试模拟试题(164)

Question:

Using the Morse Fall Risk scale (see exhibit), the nurse should initiatehighest fall risk precautions for which of the following clients? 

 

1. 84-year-old client with diabetes admitted with new-onset confusion. The client reportedly fell at home last week, is currently on bed rest, and has normal saline infusing per saline lock. 

2. 48-year-old alert and oriented client with quadriplegia admitted for wound care of a stage IV pressure ulcer, receiving IV antibiotics per a peripherally inserted central catheter. 

3. 62-year-old client with a history of Parkinson’s disease, admitted for pneumonia and receiving IV antibiotics. The client has fallen at home butis able to ambulate with a cane. During his hospitalization, he has gotten out of bed without calling for assistance. 

4. 27-year-old client with acute pancreatitis receiving morphine sulfate IV every 2 hours as needed for pain; no significant medical history, smokes two packs of cigarettes per day; may be up independently; and has steady gait. 

 

Using the Morse fall scale, risk factors for this client include history of falling, secondary diagnosis, ambulatory aid, IV/heparin lock, weak gait/transfer, and forgetting limitations (100 points). Client no. 

1 is also high risk with a secondary diagnosis, history of falling, IV access, and confusion but is on bed rest (75 points). Client no. 2 risks include IV access and secondary diagnosis (35 points). Client no. 4 is at risk due to his IV access only (20 points). 

CN: Safety and infection control; CL: Analyze

Answer:3

 小编寄语:天下事以难而废者十之一,以惰而废者十之九。——颜之推

时间:2020/1/14 10:35:07
 
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