A nurse is teaching an older adult client about fall prevention strategies at home. Which of the following client statements indicates an understanding of the teaching?
"I will secure electric cords under the carpeting.".
"I should purchase a skid-proof bathtub mat.".
"I will wear shoes with leather soles in my house.".
"I will get some rubber-backed throw rugs for my vinyl floors.".
The Correct Answer is B
Choice A rationale:
Is not a safe fall prevention strategy. Securing cords under carpeting can create tripping hazards. It is better to keep cords away from commonly used walking paths or use cord covers to prevent falls.
Choice B rationale:
Purchasing a skid-proof bathtub mat is a good fall-prevention strategy for an older adult client. It helps prevent slipping and falling in the bathroom, which is a common area for accidents in older adults.
Choice C rationale:
Is not a recommended fall prevention strategy. Leather soles can be slippery on smooth surfaces, increasing the risk of falls. Instead, the client should wear shoes with rubber soles that provide better traction.
Choice D rationale:
Is not the best option. Throw rugs, even with rubber backing, can still shift or bunch up, posing a tripping hazard. It's safer to avoid using throw rugs altogether or ensure they are firmly secured to the floor.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale:
Notifying the surgeon of the temperature elevation is important, but it is not the nurse's priority. A temperature elevation after abdominal surgery could be a sign of infection, but the immediate action should be to assess the surgical incision for any signs of infection.
Choice B rationale:
Encouraging the client to drink more fluids is a good practice to maintain hydration and promote recovery after surgery. However, it is not the nurse's priority in this situation. The elevated temperature and potential infection take precedence over increasing fluid intake.
Choice C rationale:
This is the correct answer because the nurse's priority is to assess the surgical incision for signs of infection. An elevated temperature is a significant finding after surgery, and it may indicate a surgical site infection, which requires prompt assessment and intervention.
Choice D rationale:
Monitoring vital signs every 4 hours is an essential nursing intervention after surgery, but it is not the priority when the client has an elevated temperature and a recent surgical incision.
The nurse must first assess for signs of infection before proceeding with routine vital sign monitoring.
Correct Answer is B
Explanation
Choice A rationale:
Administering furosemide may be appropriate for managing ascites, but it is not directly related to preventing complications. Furosemide is a diuretic that helps reduce fluid retention but does not address other potential complications of liver cirrhosis.
Choice B rationale:
Weighing the client weekly is essential to monitor changes in body weight and fluid status, which is crucial in detecting worsening ascites or fluid retention. Sudden weight gain could indicate an exacerbation of ascites or other complications, warranting timely intervention.
Choice C rationale:
Offering the client a high-sodium diet is contraindicated in managing ascites. A high-sodium diet would lead to increased fluid retention and worsen the ascites, potentially exacerbating the client's condition and increasing the risk of complications.
Choice D rationale:
Administering heparin is not relevant to preventing complications in a client with liver cirrhosis and abdominal ascites. Heparin is an anticoagulant, and its use is not indicated for this particular condition.
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