A nurse is performing a home safety assessment on a client who has a hip fracture. Which of the following observations should the nurse identify as a safety hazard?

Stair carpeting is attached with carpet tacks.

Nonessential items are stored in drawers.

Magazines are stacked neatly on the stairs.

End tables are secured to the wall.

Answer and Explanation

The Correct Answer is A

Rationale:

A. Stair carpeting is attached with carpet tacks: Loose or improperly secured carpeting on stairs creates a significant tripping hazard, especially for clients with mobility limitations such as a hip fracture. Carpet tacks can cause the edges of the carpet to lift, increasing the risk of falls and further injury.

B. Nonessential items are stored in drawers: Storing nonessential items in drawers does not create an immediate fall risk or safety hazard. Keeping items organized in drawers can actually reduce clutter in walking areas, making the environment safer.

C. Magazines are stacked neatly on the stairs: Even neatly stacked magazines on stairs are a potential tripping hazard. However, the option specifies “neatly stacked,” which implies some order, though ideally items should not be on stairs at all. Carpet tacks pose a more immediate and hidden danger than visible items.

D. End tables are secured to the wall: Securing furniture prevents tipping and provides stability, which enhances safety for clients with mobility limitations. This measure decreases the risk of falls and does not pose a hazard.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is A

Explanation

Rationale:

A. Tachycardia: Tachycardia is common in diabetic ketoacidosis (DKA) due to dehydration, electrolyte imbalances, and compensatory mechanisms for hypotension. The heart rate increases to maintain adequate perfusion in response to fluid loss and acidosis.

B. HCO3 in expected range: In DKA, bicarbonate (HCO3) levels are decreased due to metabolic acidosis. The body uses bicarbonate to buffer excess ketone acids, so HCO3 is typically below the normal range, not within expected limits.

C. Increased PaCO2: In DKA, PaCO2 is usually decreased due to Kussmaul respirations (deep, rapid breathing) as the body attempts to compensate for metabolic acidosis by blowing off CO2. Elevated PaCO2 would indicate hypoventilation, which is not characteristic of DKA.

D. Hyperreflexia: DKA does not typically cause hyperreflexia. Neurological changes, if present, are more likely to involve lethargy, confusion, or coma due to severe acidosis, dehydration, and electrolyte imbalances, rather than exaggerated reflexes.

A. Pull the client's pinna down and back to apply the solution. B. Perform the procedure using sterile gloves. C. Administer the irrigation solution at room temperature to the ear D. Apply a stream of pressure as long as the client can tolerate.

Correct Answer is C

Explanation

Rationale:

A. Pull the client's pinna down and back to apply the solution.: Pulling the pinna down and back is the correct technique for infants and young children due to the angle of the ear canal. For adults, the pinna should be pulled up and back to straighten the ear canal. Using the incorrect direction can prevent proper visualization and reduce effectiveness of the irrigation.

B. Perform the procedure using sterile gloves.: Ear irrigation is a clean procedure, not a sterile one. The external ear canal is not a sterile environment, and using sterile gloves does not reduce infection risk. Clean gloves provide adequate protection while maintaining proper hygiene during cerumen removal.

C. Administer the irrigation solution at room temperature to the ear.: Using a solution at room temperature prevents stimulation of the vestibular system, which can cause dizziness, nausea, and vertigo. A temperature-neutral solution promotes client comfort and reduces physiologic irritation while effectively helping soften and remove cerumen.

D. Apply a stream of pressure as long as the client can tolerate.: Using forceful or prolonged pressure can damage the tympanic membrane or push cerumen deeper into the canal. Irrigation should be done gently, allowing the solution to flow along the canal wall and stopping immediately if the client reports pain or dizziness to avoid injury.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

Body System	Common Adverse Effects
Head, eyes, ears, nose, and throat (HEENT)	dropdown
Cardiovascular	dropdown
Genitourinary	dropdown
Gastrointestinal	dropdown

A nurse is performing a home safety assessment on a client who has a hip fracture. Which of the following observations should the nurse identify as a safety hazard?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has diabetic ketoacidosis. Which of the following findings should the nurse expect?

Correct Answer is A

Explanation

A nurse is preparing to irrigate an adult client's ear due to cerumen accumulation. Which of the following actions should the nurse take?

Correct Answer is C

Explanation

A nurse on a postpartum unit is caring for a client. Exhibits Drag words from the choices below to fill in each blank in the following sentence. The nurse should anticipate provider's prescription for a(n)dropdown and dropdown.

A nurse is planning to delegate the fasting blood glucose testing for a client who has diabetes mellitus to an assistive personnel (AP). Which of the following actions should the nurse take?

A nurse in an emergency department is caring for a client who is experiencing a morphine overdose. Which of the following medications should the nurse anticipate administering to the client?

A nurse is caring for a client who has a thoracic spine injury. Which of the following actions should the nurse take when turning the client?

Exhibits A nurse is reviewing the medical record of a client who has schizophrenia. Which of the following findings should the nurse report to the provider? (Click on the exhibit tabs for additional information about the client. There are three tabs that contain separate categories of data.)

A nurse is caring for a client who is receiving oxytocin and notes that the electronic fetal monitor shows persistent late decelerations. Which of the following actions should the nurse take?

A nurse is caring for a client who is receiving continuous enteral feedings. Which of the following actions should the nurse take? (Select all that apply)