A 71-year-old patient enters the emergency department after falling down stairs in the home. The nurse is conducting a fall history with the patient and his wife. They live in a one-level ranch home. He has had diabetes for over 15 years and experiences some numbness in his feet. He wears bifocal glasses. His blood pressure is stable at 130/70. The patient does not exercise regularly and states that he experiences weakness in his legs when climbing stairs. He is alert, oriented, and able to answer questions clearly. What are the fall risk factors for this patient? (Select all that apply.)

Correct Answer: A

Rationale: The correct answer is A: Impaired vision. The patient's bifocal glasses indicate vision impairment, which is a significant fall risk factor as it affects depth perception and balance. This is evident as the patient experiences weakness in his legs when climbing stairs, which could be due to the visual impairment affecting his ability to judge distance and steps. The other choices are incorrect: Residence design (B) is not a factor since they live in a one-level ranch home; Blood pressure (C) is stable and not a fall risk factor in this case; Leg weakness (D) is a symptom of the patient's diabetes and could contribute to falls but is not the primary risk factor in this scenario.

Correct Answer: A

Rationale: The correct answer is A: On the left side. Placing the patient on the left side helps to improve ventilation-perfusion (V/Q) matching by allowing the unaffected left lung to expand fully. This position can help redistribute blood flow to the functioning lung, improving oxygenation. Choice B: On the right side would not be appropriate as it would further compromise the affected right lung. Choice C: In a reclining chair bed may not be ideal for promoting optimal lung expansion and V/Q matching. Choice D: Supine with the head of the bed elevated may not be as effective in improving V/Q matching compared to positioning on the left side.

Correct Answer: D

Rationale: The correct answer is D because in a large pulmonary embolism, a blood clot obstructs blood flow in the pulmonary arteries, leading to decreased blood flow to parts of the lungs despite adequate breathing. This mismatch between ventilation and perfusion causes respiratory failure. A is incorrect because thick membranes between air sacs and lung circulation do not play a significant role in pulmonary embolism. B is incorrect as it describes bronchial blockage, not pulmonary embolism. C is incorrect because it describes a mismatch in ventilation and perfusion but does not specifically relate to decreased blood flow due to a pulmonary embolism.

Correct Answer: C

Rationale: Step-by-step rationale for the correct answer (C): 1. Urinary tract infection (UTI) triggers a systemic inflammatory response. 2. Systemic inflammation can lead to a condition called sepsis. 3. Sepsis can cause widespread inflammation in the body, including the lungs. 4. This generalized inflammation can result in damage to the lung tissue, leading to acute respiratory distress syndrome (ARDS). Summary of why other choices are incorrect: A: Incorrect because UTI does not directly spread to the lungs through circulation. B: Incorrect because toxins produced by UTI typically affect the urinary system, not the lungs. D: Incorrect because fever associated with infection does not directly cause scar tissue formation in the lungs.

Correct Answer: D

Rationale: The correct answer is D because in acute respiratory failure, the goal is to maintain adequate oxygenation while avoiding oxygen toxicity. Keeping PaO2 at ≥60 mm Hg ensures tissue oxygenation without causing harm. Low-flow devices like nasal cannula (A) may not provide sufficient oxygen. Correcting PaO2 to normal levels quickly (B) can lead to oxygen toxicity. Positive-pressure ventilation (C) is indicated in severe respiratory failure, not for all patients in acute respiratory failure.