A charge nurse is observing a newly licensed nurse care for a client who is at risk for falls. Which of the following findings should the nurse identify as a risk factor for falls?
Positions the bedside table close to the client
Keeps the client's bed in the low position
Attaches the call light to the side rail of the client's bed
Instructs the client to wear their own socks to the bathroom
The Correct Answer is D
Choice A: This is incorrect because positioning the bedside table close to the client can help them reach their personal items and reduce the need to get out of bed.
Choice B: This is incorrect because keeping the client's bed in the low position can prevent injuries in case of a fall and make it easier for the client to get in and out of bed.
Choice C: This is incorrect because attaching the call light to the side rail of the client's bed can ensure that the client can access it easily and call for assistance when needed.
Choice D: This is correct because instructing the client to wear their own socks to the bathroom can increase the risk of slipping and falling. The client should wear non-skid footwear or slippers when walking.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A reason: Performing breast exams every other month is not an adequate frequency, as it can delay the detection of any changes or abnormalities. The client should perform breast exams monthly, preferably a few days after their period ends.
Choice B reason: Having one breast larger than the other is a common variation and not a cause for concern, unless there is a sudden change in size or shape. The client should be aware of their normal breast appearance and report any changes to their provider.
Choice C reason: Performing breast exams the day their period begins is not an optimal time, as their breasts may be swollen, tender, or lumpy due to hormonal fluctuations. The client should perform breast exams when their breasts are not affected by their menstrual cycle, such as a week after their period ends.
Choice D reason: Having skin dimpling on their breasts is not a common variation and may indicate an underlying tumor that pulls on the connective tissue and causes puckering of the skin. The client should inspect their breasts for any changes in skin texture, such as dimpling, peau d'orange, or redness, and report them to their provider.
Correct Answer is B
Explanation
Choice A reason: Passing of flatus is not a reliable indicator of colostomy function, as it can occur even when there is an obstruction or ischemia in the bowel.
Choice B reason: Stoma is pinkish-red is a sign of a healthy and well-perfused colostomy, as it indicates that the blood supply to the bowel segment is adequate and there is no necrosis or infection.
Choice C reason: Tolerating a clear liquid diet is not a specific indicator of colostomy function, as it does not reflect the amount or consistency of the stool output.
Choice D reason: Absent bowel sounds are not a normal finding for a colostomy, as they can indicate a paralytic ileus or a bowel obstruction, which can cause complications such as distension, pain, or perforation.
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