A nurse is evaluating a patient who has a stage 1 pressure injury. What findings should the nurse anticipate?

Choice A rationale

The presence of a grab bar in the bathroom is actually a safety measure that can help prevent falls. It provides support for the patient when they are getting up or moving around, reducing the risk of a fall.

Choice B rationale

An electrical cord lying across a walkway is a tripping hazard and would increase the patient’s risk of falling. It is important to keep walkways clear of clutter and potential obstacles to prevent falls.

Choice C rationale

Macular degeneration can affect the patient’s vision, making it difficult for them to see obstacles or changes in the walking surface. This can increase their risk of falling.

Choice D rationale

Throw rugs in the kitchen can easily slip or bunch up, creating a tripping hazard. They should be secured with non-slip backing or removed to reduce the risk of falls.

Choice E rationale

While a cane can provide support and improve balance, it also indicates that the patient has mobility issues, which increases their risk of falling. It is important that the patient uses the cane correctly and that it is the right height for them.

Choice A rationale

Donning sterile gloves before inserting the indwelling urinary catheter is a critical step to prevent infection. The urinary tract is normally sterile, and using sterile gloves helps maintain this sterility during the procedure.

Choice B rationale

Applying an oil-based lubricant to the indwelling urinary catheter is not recommended. Oil- based lubricants can damage latex catheters and increase the risk of infection. A water-soluble lubricant is typically used.

Choice C rationale

Using one cotton swab to clean the client’s genitalia is not sufficient. Proper cleaning and disinfection of the area are crucial to prevent introducing bacteria into the urinary tract during catheter insertion.

Choice D rationale

Testing the balloon on the indwelling urinary catheter before insertion is not typically done. The balloon is usually inflated with sterile water once the catheter is in place to ensure that it remains in the bladder.