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: Showing the client a video demonstration of peak flow meter use is a helpful teaching strategy, but it is not the first action that the nurse should take. The nurse should first assess the client's baseline knowledge and readiness to learn before providing any information or instruction.
Choice B reason: Observing the client using the peak flow meter is a way to evaluate the client's learning and skill, but it is not the first action that the nurse should take. The nurse should first determine the client's knowledge of the use of the peak flow meter and then teach the client how to use it correctly.
Choice C reason: Emphasizing the importance of the daily use of the peak flow meter is a way to motivate the client to adhere to the treatment plan, but it is not the first action that the nurse should take. The nurse should first assess the client's knowledge of the use of the peak flow meter and then explain the benefits and rationale of using it regularly.
Choice D reason: Determining the client's knowledge of the use of the peak flow meter is the first action that the nurse should take, as it follows the principle of the nursing process. The nurse should start with assessment, then proceed with planning, implementation, and evaluation. By assessing the client's knowledge, the nurse can identify the client's learning needs, gaps, and preferences, and tailor the teaching accordingly.
Correct Answer is D
Explanation
Choice A reason: This is incorrect because the client should urinate before the specimen collection to avoid contaminating the stool with urine.
Choice B reason: This is incorrect because the specimen should be kept in a cool area to prevent bacterial growth and decomposition.
Choice C reason: This is incorrect because the client should place at least 2.5 cm (1 in) of formed stool or 15 to 30 mL of liquid stool into a culture tube.
Choice D reason: This is correct because the client should avoid placing toilet tissue in the bedpan after defecation to prevent interfering with the laboratory analysis of the stool.
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