A nurse enters a client's room after an assistive personnel (AP) has completed morning care. The client is 2 days postoperative following a total knee arthroplasty and is resting in bed. Which of the following observations requires the nurse to intervene and follow-up with the AP?
The client's IV pump is placed at the head of the bed.
The client's call light is pinned to the bed sheet.
The client's water pitcher is located on the bedside table.
The client's walker is next to the bathroom door.
The Correct Answer is B
A. The client's IV pump is placed at the head of the bed:
This is an appropriate placement to prevent tripping hazards and keep the pump accessible.
B. The client's call light is pinned to the bed sheet:
Pinning the call light can make it inaccessible if the sheet moves, increasing the risk that the client cannot summon help quickly-especially important for post-op clients at risk of falls.
C. The client's water pitcher is located on the bedside table:
This is an appropriate and accessible placement.
D. The client's walker is next to the bathroom door:
The walker should be within reach of the client’s bed or chair to promote safe mobility; however, if the client is resting in bed, this is not as urgent as the call light issue.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Occupational therapist:
OTs focus on helping clients regain skills for daily living, not arranging transportation.
B. Physical therapist:
PTs assist with mobility and exercise, but transportation arrangements are not their role.
C. Social worker:
Social workers coordinate community resources, including transportation assistance, home services, and support systems for clients after discharge.
D. Dietitian:
Dietitians address nutritional needs, not transportation.
Correct Answer is B
Explanation
A. Document in the nurses' notes that an incident report was completed:
This is incorrect. The incident report is an internal risk management tool and should not be mentioned in the medical record.
B. Record the facts about the incident in the medical record:
The nurse should document objective facts about the event, assessment, and interventions in the client’s medical record without referencing the incident report.
C. Provide the family with a copy of the incident report:
Incident reports are confidential and not shared with clients or families.
D. Place a copy of the incident report in the medical record:
This is incorrect; incident reports are kept separately from the medical record to avoid legal complications.
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