A nurse is reinforcing home safety instructions for a patient with a history of falls.
Which statement should the nurse identify as an indication that the patient understands the instructions?
“I will place a bath seat in my shower to use when I bathe.”.
“I will keep the fluorescent ceiling light on in my room at night.”.
“I will place an area rug at the entry of my bathroom.”.
“I will keep my walker at the end of my bed.”. .
The Correct Answer is A
Choice A rationale
Placing a bath seat in the shower is a good safety measure for a patient with a history of falls. It allows the patient to sit while bathing, reducing the risk of slipping and falling.
Choice B rationale
Keeping the fluorescent ceiling light on in the room at night can actually increase the risk of falls. It can create shadows and glare that can be disorienting, especially for older adults.
Choice C rationale
Placing an area rug at the entry of the bathroom is not recommended. Rugs can easily become tripping hazards, especially if they’re not secured to the floor.
Choice D rationale
Keeping a walker at the end of the bed can be helpful for some patients, but it’s not the best indication that the patient understands home safety instructions. It’s important that the walker is used correctly and that the patient’s home is arranged to accommodate its use.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale
Slough, which is a layer of yellowish, dead tissue that can develop on the surface of a wound, is not a defining characteristic of a stage 3 pressure ulcer.
Choice B rationale
Persistent reddening of the skin is typically associated with a stage 1 pressure ulcer, not a stage 3. In a stage 1 pressure ulcer, the skin remains intact but may be red and may not blanch (lose color briefly) when you press your finger on it.
Choice C rationale
A stage 3 pressure ulcer involves full-thickness skin loss that appears as a deep crater. The ulcer may extend into the subcutaneous tissue layer, but not through it to the underlying
muscle or bone. This description matches the statement in Choice C, making it the correct answer.
Choice D rationale
A fluid-filled area under the skin could potentially indicate a blister or a stage 2 pressure ulcer, not a stage 3. In a stage 2 pressure ulcer, the outer layer of skin (epidermis) and part of the underlying layer of skin (dermis) are damaged or lost.
Correct Answer is D
Explanation
The correct answer is Choice D
Choice A rationale: A 1-inch needle is typically used for intramuscular injections, not intradermal administration. Intradermal injections require a short, fine-gauge needle—usually ¼ to ⅝ inch in length and 25 to 27 gauge—to ensure accurate placement within the dermis. Using a longer needle increases the risk of injecting into subcutaneous tissue, which alters absorption and invalidates the test. Scientific technique demands precise needle selection based on anatomical depth and pharmacokinetics of the test substance.
Choice B rationale: A 20° angle is inappropriate for intradermal injections, which require a shallow angle of 5° to 15° to ensure deposition within the dermal layer. Angles greater than 15° risk penetrating into subcutaneous tissue, compromising test accuracy and absorption kinetics. The dermis is a narrow layer between the epidermis and subcutaneous fat, and precise angulation is critical for forming the characteristic wheal and ensuring localized immune response. Scientific technique mandates strict adherence to angle parameters.
Choice C rationale: The standard volume for a tuberculin skin test using purified protein derivative (PPD) is 0.1 mL, not 0.5 mL. Administering 0.5 mL would exceed the recommended dose, potentially causing excessive local reaction, invalid test results, and patient discomfort. The Mantoux method requires exact dosing to elicit a controlled immune response for accurate interpretation. Scientific protocol emphasizes precision in volume to maintain test validity and minimize adverse effects. Overdosing violates established guidelines.
Choice D rationale: Pinching or gently pulling the skin taut at the injection site stabilizes the dermal layer and facilitates correct needle placement. This technique ensures the needle enters at the proper angle and depth, allowing formation of a visible wheal, which confirms intradermal delivery. It also minimizes patient discomfort and prevents misplacement into deeper tissues. Scientific technique for intradermal injections prioritizes anatomical control and tactile feedback to optimize accuracy and diagnostic reliability.
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