The nurse is checking the home environment of a client for safety hazards.
Which of the following items require intervention by the nurse?
The television set is turned to a loud volume.
The dining room table has low chairs with no armrests.
The bedroom extension cord is placed under a heavy nightstand.
The living room contains wall-to-wall carpeting.
The Correct Answer is C
c. The bedroom extension cord is placed under a heavy nightstand.
The nurse should intervene and address the placement of the bedroom extension cord under a heavy nightstand. This poses a safety hazard as it increases the risk of electrical fire or tripping. The nurse shouldmeducate the client about the importance of using proper outlets and avoiding the use of extension cords in general, especially when they are hidden under heavy furniture.
Options a, b, and d do not require immediate intervention by the nurse:
a. The television set turned to a loud volume can be addressed by educating the client about the potential risks of prolonged exposure to loud noises and providing guidance on appropriate volume levels.
b. The presence of low chairs with no armrests in the dining room may not necessarily require immediate intervention unless there are specific safety concerns related to the client's mobility or balance. The nurse may provide general recommendations for safer seating options, especially if the client is at risk of falls or has difficulty getting up from low chairs.
d. The presence of wall-to-wall carpeting in the living room is a common feature in many homes and does not necessarily pose a safety hazard. However, the nurse may discuss general home safety measures, such as keeping the carpet clean and free of tripping hazards, especially for clients with mobility issues.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
a. "The machine is programmed to prevent you from administering more than a safe dose."
When reinforcing teaching about epidural PCA (patient-controlled analgesia) with a client in active labor, it is important for the nurse to inform the client about the safety features of the machine. By explaining that the machine is programmed to prevent the client from administering more than a safe dose, the nurse reassures the client that they have control over their pain relief while minimizing the risk of overdose.
Option b, "During medication administration, you will not be able to move your legs freely," is not an accurate statement regarding epidural PCA. While epidural analgesia may cause temporary weakness or loss of sensation in the lower body, the ability to move the legs freely is not necessarily completely impaired. The degree of mobility can vary depending on the dosage and specific characteristics of the epidural.
Option c, "This method of pain control will shorten the second stage of labor," is not a valid statement. Epidural PCA is primarily used for pain relief during labor and delivery but does not directly affect the progression or duration of the second stage of labor, which involves pushing and the delivery of the baby.
Option d, "This type of anesthesia commonly causes a postpartum headache," is also incorrect. While headaches can occur as a potential side effect of epidural anesthesia, they are not specifically associated with epidural PCA. Postpartum headaches can have various causes and are not exclusively related to the use of epidural PCA.
By emphasizing the safety features of the machine and explaining that it prevents the administration of excessive doses, the nurse ensures that the client understands the appropriate use of the epidural PCA for pain control during labor.
Correct Answer is D
Explanation
The client's partner assisting them with their meal tray (option d) is not as important as the other information and may not need to be included in the change-of-shift report.
A nurse providing change-of-shift report for a client who has heart failure should include all of the above information in the report.
The client's most recent blood pressure reading,morning laboratory results, and presence of pitting edema in the lower extremities are all important pieces of information that the incoming nurse should be aware of.
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