A nurse is collecting data regarding home safety from a client who is prone to falls. Which of the following findings should the nurse recognize as placing the client at additional risk?

The client has removed the wheels from rolling chairs.

A stool riser is in place on the bathroom toilet.

The client’s mattress is directly on the floor.

Throw rugs cover electrical cords on the floor.

Answer and Explanation

The Correct Answer is D

Choice A reason: Removing the wheels from rolling chairs is a good practice to prevent the chairs from sliding or moving unexpectedly. It is not a risk factor for falls, but rather a safety measure to prevent them.

Choice B reason: A stool riser is a device that elevates the toilet seat and makes it easier for the client to sit down and stand up. It is not a risk factor for falls, but rather a safety measure to prevent them.

Choice C reason: Having the mattress directly on the floor may make it harder for the client to get in and out of bed, but it does not increase the risk of falls. In fact, it may reduce the risk of injury if the client falls from the bed, as the height is lower.

Choice D reason: Covering electrical cords with throw rugs is a risk factor for falls, as the client may trip over them or get tangled in them. It is also a fire hazard, as the rugs may overheat or catch fire from the cords. The nurse should advise the client to remove the rugs and secure the cords away from the walking areas.

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Correct Answer is B

Explanation

Choice A reason: Client instructed on self-care needs is not a specific or accurate documentation. The nurse should include the details of the instruction, such as the topics covered, the teaching methods used, the client's response, and the evaluation of learning.

Choice B reason: Oral temperature elevated at 0800 is a specific and accurate documentation. The nurse should include the vital signs and any abnormal findings, such as fever, in the client's health record. The nurse should also report the elevation to the provider and monitor the client for signs of infection.

Choice C reason: Episiotomy approximated, 3 cm (1.18 in) in length is not a specific or accurate documentation. The nurse should include the type, location, and degree of the episiotomy, as well as the condition of the wound, the presence of edema, erythema, or drainage, and the interventions performed.

Choice D reason: Client drank adequate amounts of fluid with meals is not a specific or accurate documentation. The nurse should include the exact amount and type of fluid intake, as well as the output, in the client's health record. The nurse should also assess the client for signs of dehydration or fluid overload.

A. Using an oral care sponge swab moistened with cool water to clean the client's mouth. B. Wearing clean gloves to perform mouth care for the client. C. Lowering the side rail on the side of the bed where they will stand to perform mouth care. D. Using two gloved fingers to open the client's mouth for cleaning. E. None F. None

Correct Answer is D

Explanation

The correct answer is d. Using two gloved fingers to open the client’s mouth for cleaning. This action is unsafe as it risks injury to both the AP and the client. A padded tongue blade should be used instead.

Choice A reason:

Using an oral care sponge swab moistened with cool water to clean the client’s mouth is appropriate. Oral care sponge swabs are designed to clean the mouth gently and effectively, especially for unconscious patients.

Choice B reason:

Wearing clean gloves to perform mouth care for the client is a standard precaution to prevent infection. Gloves protect both the caregiver and the patient from potential infections.

Choice C reason:

Lowering the side rail on the side of the bed where they will stand to perform mouth care is necessary to safely access the patient. It allows the AP to perform the task without straining or risking injury.

Choice D reason:

Using two gloved fingers to open the client’s mouth for cleaning is unsafe. This method can cause injury to the AP if the patient bites down reflexively. A padded tongue blade should be used to safely open the mouth.

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A nurse is collecting data regarding home safety from a client who is prone to falls. Which of the following findings should the nurse recognize as placing the client at additional risk?

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