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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A reason: A small banana contains about 8.7 mg of vitamin C, which is only 10% of the recommended daily intake for adults.
Choice B reason: A medium fresh green pear contains about 4.3 mg of vitamin C, which is only 5% of the recommended daily intake for adults.
Choice C reason: A small pink grapefruit contains about 38.4 mg of vitamin C, which is 43% of the recommended daily intake for adults. This is the highest amount of vitamin C among the four choices.
Choice D reason: A small apple with the skin contains about 8.4 mg of vitamin C, which is only 9% of the recommended daily intake for adults.
Correct Answer is C
Explanation
Choice A reason: This is not the correct answer because greenish-yellow drainage is a normal color for gastric secretions and does not indicate a problem.
Choice B reason: This is not the correct answer because a report of hunger is common for a client with an NG tube and does not require intervention.
Choice C reason: This is the correct answer because gastric contents in the air vent mean that the NG tube is clogged or kinked and needs to be flushed or replaced. This is the correct answer because it indicates that the NG tube is not functioning properly and could cause aspiration or infection. The other findings are expected or normal for a client with an NG tube.
Choice D reason: This is not the correct answer because abdominal distention is a common reason for placing an NG tube and should improve with gastric decompression.
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