A home health nurse is conducting a home inspection for a client who is at risk for falls. Which of the following instructions should the nurse provide for the client?
Place the bedside table 2 feet away from the bed.
Move the client's bed to the main floor of the house.
Keep lighting in the home dim.
Place area rugs on slick floor surfaces.
The Correct Answer is B
A. Incorrect. The bedside table should be within easy reach of the bed to prevent the client from attempting to reach for items and potentially falling.
B. Correct. Moving the client's bed to the main floor of the house reduces the need for using stairs, which can be a fall risk for clients at risk for falls.
C. Incorrect. Keeping the lighting dim increases the risk of falls. Adequate lighting is important to prevent falls.
D. Incorrect. Area rugs on slick floor surfaces can be hazardous and increase the risk of falls.
They should be removed or secured properly.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Incorrect. Placing the bedside table within easy reach of the bed is important to prevent falls, rather than placing it away from the bed.
B. Correct. Moving the client's bed to the main floor of the house reduces the need to use stairs, which can be a fall risk for clients at risk of falls.
C. Incorrect. Keeping the lighting dim increases the risk of falls. Adequate lighting is important to prevent falls.
D. Incorrect. Area rugs on slick floor surfaces can be hazardous and increase the risk of falls.
They should be removed or secured properly.
Correct Answer is B
Explanation
Some gastrostomy tubes require an extension set for feeding, especially low-profile devices (e.g., button-type gastrostomy tubes). This extension makes it easier to administer feeds or medications and can be removed afterward. However, this is not typically part of routine site care.
Taping the tube to the child's cheek is not typically done as it can cause discomfort and skin irritation. The tube should be secured with a stabilization device or a specialized dressing designed for gastrostomy tube care.
Applying a skin barrier protectant around the gastrostomy site is a good practice. It helps protect the skin from irritation, breakdown, and leakage of gastric contents, which can cause skin excoriation. This helps maintain the integrity of the skin around the site.
Applying water-soluble lubricant to the site is not necessary for routine site care. Lubrication is typically used when inserting or removing the tube, but it is not part of routine site care.

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