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 B
Explanation
Choice A reason: This is incorrect because the crutch tips should be about 15 cm (6 inches) away from the feet to provide stability and prevent tripping.
Choice B reason: This is correct because the three-point gait involves bearing weight on the unaffected leg while moving both crutches and the affected leg forward at the same time.
Choice C reason: This is incorrect because the crutches should be at the level of the hips, not the waist, to avoid pressure on the axillae and nerves.
Choice D reason: This is incorrect because the arms should be slightly bent at the elbows when walking to reduce fatigue and strain.
Correct Answer is B
Explanation
Choice A reason: Witnessing the client’s signature on a consent form is not necessary for an indwelling urinary catheter insertion, which is a routine and noninvasive procedure. The nurse only needs to witness the signature for invasive or high-risk procedures that require written consent.
Choice B reason: Obtaining verbal consent from the client is the appropriate action for the nurse to take before inserting an indwelling urinary catheter. The nurse should explain the purpose, benefits, risks, and alternatives of the procedure and ensure that the client understands and agrees to it.
Choice C reason: Having another nurse co-sign the client’s consent is not required for an indwelling urinary catheter insertion, which is a routine and noninvasive procedure. The nurse only needs to have another nurse co-sign the consent for procedures that involve blood transfusions, organ donations, or research participation.
Choice D reason: Checking the medical record for the client’s signature on a previous consent form is not sufficient for verifying the client’s express consent for an indwelling urinary catheter insertion. The nurse should obtain a new consent for each procedure, as the client has the right to change their mind or refuse the treatment at any time.
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