A nurse is collecting data regarding home safety from a client who is prone to falls. Which of the following findings should the nurse recognize as placing the client at additional risk?
The client has removed the wheels from rolling chairs.
A stool riser is in place on the bathroom toilet.
The client’s mattress is directly on the floor.
Throw rugs cover electrical cords on the floor.
The Correct Answer is D
Choice A reason: Removing the wheels from rolling chairs is a good practice to prevent the chairs from sliding or moving unexpectedly. It is not a risk factor for falls, but rather a safety measure to prevent them.
Choice B reason: A stool riser is a device that elevates the toilet seat and makes it easier for the client to sit down and stand up. It is not a risk factor for falls, but rather a safety measure to prevent them.
Choice C reason: Having the mattress directly on the floor may make it harder for the client to get in and out of bed, but it does not increase the risk of falls. In fact, it may reduce the risk of injury if the client falls from the bed, as the height is lower.
Choice D reason: Covering electrical cords with throw rugs is a risk factor for falls, as the client may trip over them or get tangled in them. It is also a fire hazard, as the rugs may overheat or catch fire from the cords. The nurse should advise the client to remove the rugs and secure the cords away from the walking areas.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A reason: "I will keep your personal information private." is not a statement of advocacy, but a statement of confidentiality. Confidentiality is the ethical and legal obligation of the nurse to protect the client's privacy and information. Advocacy is the act of supporting and protecting the client's rights and interests.
Choice B reason: "I will do my best to fulfill my promises to you." is not a statement of advocacy, but a statement of accountability. Accountability is the responsibility of the nurse to answer for their actions and outcomes. Advocacy is the act of supporting and protecting the client's rights and interests.
Choice C reason: "I will speak with your provider on your behalf." is not a statement of advocacy, but a statement of communication. Communication is the exchange of information and ideas between the nurse and the client, the provider, and other members of the health care team. Advocacy is the act of supporting and protecting the client's rights and interests.
Choice D reason: "I will let you make decisions about your health care." is a statement of advocacy. Advocacy is the act of supporting and protecting the client's rights and interests, such as the right to informed consent, self-determination, and autonomy. The nurse should respect the client's choices and preferences, and assist them in making informed decisions.
Correct Answer is A
Explanation
Choice A reason: Gloves are the first piece of personal protective equipment that the nurse should remove, as they are the most contaminated and can transfer microorganisms to other surfaces. The nurse should remove the gloves by grasping the outside of one glove at the wrist and pulling it off inside out, then holding it in the gloved hand and sliding the fingers of the ungloved hand under the other glove at the wrist and pulling it off inside out over the first glove. The nurse should then discard the gloves in a biohazard container.
Choice B reason: Goggles are the second piece of personal protective equipment that the nurse should remove, as they can protect the eyes from splashes or droplets. The nurse should remove the goggles by grasping the earpieces or headband and lifting them away from the face. The nurse should then discard the goggles in a designated receptacle or place them in a designated area for reprocessing.
Choice C reason: Gown is the third piece of personal protective equipment that the nurse should remove, as it can protect the clothing and skin from contamination. The nurse should remove the gown by untying the neck and waist ties and pulling the gown away from the neck and shoulders, touching only the inside of the gown. The nurse should then turn the gown inside out, fold or roll it into a bundle, and discard it in a biohazard container.
Choice D reason: Mask is the last piece of personal protective equipment that the nurse should remove, as it can protect the nose and mouth from inhalation of microorganisms. The nurse should remove the mask by grasping the bottom ties or elastics and then the top ties or elastics and pulling the mask away from the face. The nurse should then discard the mask in a biohazard container.
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