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.
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
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Rationale:
A. "Can you tune out the voices by listening to music?": This question focuses on coping strategies, which is important, but it is not the immediate priority. The nurse must first assess the content of the hallucinations to determine potential risk.
B. "Are you also seeing unusual persons or things?": Assessing for visual hallucinations is useful, but the client is currently experiencing auditory command hallucinations. Immediate focus should be on the commands to ensure safety.
C. "What are the voices telling you to do?": Determining the content of the voices is the priority because command hallucinations may instruct the client to harm themselves or others. Assessing risk and ensuring safety comes before exploring coping or additional symptoms.
D. "Do the voices cause you to feel anxious?": Assessing emotional response is relevant, but it is secondary to understanding whether the hallucinations pose a safety risk to the client or others.
Correct Answer is C
Explanation
Rationale:
A. Increase the rate of the oxytocin infusion: Increasing oxytocin would intensify uterine contractions, which can worsen uteroplacental insufficiency and exacerbate late decelerations. This action is unsafe and contraindicated when late decelerations are present.
B. Administer dinoprostone transvaginally: Dinoprostone is used to ripen the cervix or induce labor, not to correct fetal distress caused by uteroplacental insufficiency. Administering it in this scenario would not address the underlying problem and could increase fetal risk.
C. Place the client in a lateral position: Lateral positioning improves uteroplacental blood flow and oxygen delivery to the fetus, which can reduce late decelerations. It is an immediate, safe, and effective nursing intervention to relieve fetal stress caused by decreased placental perfusion.
D. Assist the client to empty their bladder: While bladder distention can affect uterine contractions and comfort, it does not directly address late decelerations. Emptying the bladder may be beneficial for other reasons, but repositioning the client takes priority in improving fetal oxygenation.
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