A home health care nurse is conducting a fall risk assessment for a client who has osteoarthritis and lives alone. The nurse should identify that which of the following factors creates a risk for falls?

Large pieces of furniture.

A bedside table next to the bed.

Raised toilet seats.

Throw rugs on hardwood floors.

Answer and Explanation

The Correct Answer is D

Choice A rationale:

Large pieces of furniture do not necessarily create a significant risk for falls unless they are poorly placed or obstructing pathways. While they can potentially cause accidents, the likelihood of tripping over them is generally lower compared to other hazards.

Choice B rationale:

A bedside table next to the bed is not a significant fall risk factor. In fact, having a bedside table can be beneficial for the client, as it provides a convenient surface for placing items that the client might need during the night.

Choice C rationale:

Raised toilet seats, although they may pose a challenge for individuals with mobility issues, are typically installed to aid those with difficulty sitting down or standing up. They are not a primary risk factor for falls, especially when compared to other more hazardous factors.

Choice D rationale:

Throw rugs on hardwood floors are a significant fall risk factor, especially for older adults or individuals with mobility problems. The rugs can easily shift or bunch up, causing someone to trip and fall. Hardwood floors can also become slippery, and the combination of a throw rug on such a surface increases the risk of accidents. The rationale behind this choice is grounded in the potential for tripping and slipping hazards that these throw rugs can introduce, especially in individuals who might already have balance or mobility issues.

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Correct Answer is D

Explanation

The correct answer is choiced. “I will wear gloves when changing the client’s hospital gown.”

Choice A rationale:

Cleaning reusable equipment with isopropyl alcohol is not effective against Clostridium difficile spores. Equipment should be cleaned with a sporicidal disinfectant to ensure the removal of C.difficile spores.

Choice B rationale:

Alcohol-based hand sanitizers are not effective against C. difficile spores.Hand hygiene should be performed with soap and water after contact with the client or their environment.

Choice C rationale:

Wearing a mask within 3 feet of the client is not necessary for C. difficile infection, as it is not transmitted via respiratory droplets.The primary mode of transmission is through contact with contaminated surfaces or feces.

Choice D rationale:

Wearing gloves when changing the client’s hospital gown is essential to prevent the transmission of C. difficile spores.Gloves should be worn for all contact with the client or their environment

A. Measure the amount of aspirate in the NG tube. B. Flush the tube with 50 mL of tap water. C. Examine the color of aspirated secretions. D. Measure the pH of the client's aspirate. E. Obtain an x-ray of the client's chest and abdomen.

Correct Answer is ["A","C","D","E"]

Explanation

Choice A rationale:

Measuring the amount of aspirate in the NG tube is one way to verify the placement of the tube. Aspirate should be tested for color, pH, and other characteristics to ensure proper positioning.

Choice B rationale:

Flushing the tube with tap water doesn't directly verify tube placement. This action might inadvertently introduce air into the tube, potentially leading to inaccurate assessment results.

Choice C rationale:

Examining the color of aspirated secretions is an essential step in verifying tube placement. Different colors of aspirate can indicate different anatomical locations, helping to ensure the tube is properly positioned.

Choice D rationale:

Measuring the pH of the client's aspirate is another important method to verify NG tube placement. Gastric aspirate tends to be acidic, while respiratory aspirate is usually more alkaline.

Choice E rationale:

Obtaining an x-ray of the client's chest and abdomen is a definitive method for confirming NG tube placement. It provides direct visualization of the tube's location and ensures accuracy.

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A home health care nurse is conducting a fall risk assessment for a client who has osteoarthritis and lives alone. The nurse should identify that which of the following factors creates a risk for falls?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is reviewing transmission precautions with an assistive personnel (AP) who is providing care for a client who has a Clostridium difficile infection. Which of the following statements by the AP indicates an understanding of the teaching?

Correct Answer is D

Explanation

A nurse is inserting an NG tube for a client who has a new prescription for enteral feedings. Which of the following actions should the nurse take to verify the placement of the client's tube? (Select all that apply.).

Correct Answer is ["A","C","D","E"]

Explanation

A home health care nurse is conducting a fall risk assessment for a client who has osteoarthritis and lives alone. The nurse should identify that which of the following factors creates a risk for falls?

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