A charge nurse is observing a newly licensed nurse care for a client who is at risk for falls. Which of the following findings should the nurse identify as a risk factor for falls?
Positions the bedside table close to the client
Keeps the client's bed in the low position
Attaches the call light to the side rail of the client's bed
Instructs the client to wear their own socks to the bathroom
The Correct Answer is D
Choice A: This is incorrect because positioning the bedside table close to the client can help them reach their personal items and reduce the need to get out of bed.
Choice B: This is incorrect because keeping the client's bed in the low position can prevent injuries in case of a fall and make it easier for the client to get in and out of bed.
Choice C: This is incorrect because attaching the call light to the side rail of the client's bed can ensure that the client can access it easily and call for assistance when needed.
Choice D: This is correct because instructing the client to wear their own socks to the bathroom can increase the risk of slipping and falling. The client should wear non-skid footwear or slippers when walking.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A: This is correct because offering artificial saliva frequently can help moisten the mouth and improve the taste of food. Radiation therapy can cause dry mouth and altered taste sensation.
Choice B: This is incorrect because providing three large meals daily can be overwhelming and unappetizing for the client. The nurse should provide small, frequent meals that are high in protein and calories.
Choice C: This is incorrect because adding honey to sweeten fruit smoothies can irritate the throat and increase the risk of infection. The nurse should avoid foods that are acidic, spicy, or sticky.
Choice D: This is incorrect because heating food before serving can enhance the unpleasant taste and smell of food. The nurse should serve food cold or at room temperature.
Correct Answer is C
Explanation
Choice A reason: Applying moist heat to the incision while in bed is not an appropriate instruction, as it can increase the risk of infection, bleeding, or swelling at the site. The nurse should instruct the client to keep the incision dry and covered with a sterile dressing.
Choice B reason: Performing range of motion by adducting the hip is not an appropriate instruction, as it can cause dislocation or damage to the prosthesis. The nurse should instruct the client to avoid crossing their legs or turning their toes inward and to use an abduction pillow or wedge between their legs.
Choice C reason: Sitting in a straight-backed chair is an appropriate instruction, as it can prevent flexion contractures and promote circulation and healing in the hip joint. The nurse should instruct the client to use a raised toilet seat and a chair with armrests and avoid sitting for longer than 45 min at a time.
Choice D reason: Cleansing the surgical incision with hydrogen peroxide is not an appropriate instruction, as it can irritate or damage the tissue and delay wound healing. The nurse should instruct the client to use mild soap and water or saline solution to clean the incision and pat it dry gently.
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