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 C
Explanation
Choice A reason: WBC count 10,000/mm³ is within the normal range of 4,500 to 11,000/mm³ and does not indicate any infection or inflammation.
Choice B reason: BUN 20 mg/dL is within the normal range of 10 to 20 mg/dL and does not indicate any renal impairment or dehydration.
Choice C reason: Creatinine 2.3 mg/dL is above the normal range of 0.6 to 1.2 mg/dL and indicates renal dysfunction or damage, which can be caused by blood loss, hypotension, or nephrotoxic drugs during surgery. The nurse should report this value to the provider and monitor the client for signs of acute kidney injury, such as oliguria, edema, or electrolyte imbalances.
Choice D reason: Hematocrit 41% is within the normal range of 37% to 47% for females and does not indicate any anemia or polycythemia.
Correct Answer is D
Explanation
Choice A: This is incorrect because stool being a dark green color is not a finding that the nurse should report to the provider. Stool from an ileostomy can be dark green, brown, or yellow depending on the diet and fluid intake of the client.
Choice B: This is incorrect because stoma being a cherry red color is not a finding that the nurse should report to the provider. Stoma from an ileostomy should be moist and pink or red, indicating adequate blood supply and healing.
Choice C: This is incorrect because stool containing scant red blood is not a finding that the nurse should report to the provider. Stool from an ileostomy can contain small amounts of blood due to irritation or inflammation of the bowel mucosa.
Choice D: This is correct because stoma retracting into the abdominal wall is a finding that the nurse should report to the provider. Stoma from an ileostomy should protrude slightly above the skin level, allowing for proper drainage and appliance fitting. Stoma retraction can indicate ischemia, obstruction, or peritonitis.
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