A nurse is performing a home safety assessment on a client who has a hip fracture. Which of the following observations should the nurse identify as a safety hazard?
Stair carpeting is attached with carpet tacks.
Nonessential items are stored in drawers.
Magazines are stacked neatly on the stairs.
End tables are secured to the wall.
The Correct Answer is A
Rationale:
A. Stair carpeting is attached with carpet tacks: Loose or improperly secured carpeting on stairs creates a significant tripping hazard, especially for clients with mobility limitations such as a hip fracture. Carpet tacks can cause the edges of the carpet to lift, increasing the risk of falls and further injury.
B. Nonessential items are stored in drawers: Storing nonessential items in drawers does not create an immediate fall risk or safety hazard. Keeping items organized in drawers can actually reduce clutter in walking areas, making the environment safer.
C. Magazines are stacked neatly on the stairs: Even neatly stacked magazines on stairs are a potential tripping hazard. However, the option specifies “neatly stacked,” which implies some order, though ideally items should not be on stairs at all. Carpet tacks pose a more immediate and hidden danger than visible items.
D. End tables are secured to the wall: Securing furniture prevents tipping and provides stability, which enhances safety for clients with mobility limitations. This measure decreases the risk of falls and does not pose a hazard.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Rationale:
A. Maintain sensory stimulation for the client: While in restraints, minimizing overstimulation is important to reduce agitation and prevent further aggressive behavior. Excessive sensory input can increase stress and escalate the situation rather than support safety.
B. Identify stressors that caused the client's aggression: Understanding triggers is important for long-term behavior management, but it is not the priority while the client is physically restrained. Immediate safety and monitoring take precedence over retrospective analysis.
C. Observe the client's range of movement: Continuous monitoring of the client’s range of motion is essential while restraints are in place to prevent injury, nerve damage, or impaired circulation. Regular checks ensure the restraints are applied safely and that the client maintains mobility as much as possible within safety limits.
D. Hold a critical incident debriefing about the client: Debriefing is important for staff learning and emotional processing after the event, but it occurs after the client is safe and restraints are removed. It is not an action to be performed while the client is restrained.
Correct Answer is B
Explanation
Rationale:
A. Shoulders: The shoulders are usually covered with clothing and have more pigmentation and subcutaneous tissue, making color changes less apparent. Cyanosis may be difficult to detect in these areas, especially in clients with dark skin.
B. Palms of the hands: The palms, along with the soles of the feet, nail beds, and mucous membranes, have less melanin and are more reliable sites to observe for cyanosis in clients with dark skin. These areas can show a bluish or grayish discoloration more accurately when oxygenation is low.
C. Area of trauma: Trauma sites may exhibit bruising, erythema, or inflammation, which can mask the presence of cyanosis. Assessing these areas may lead to inaccurate conclusions regarding oxygenation status.
D. Sacrum: While the sacrum may be assessed for pressure injuries, it is not a reliable site for detecting cyanosis because of pigmentation, limited blood flow, and potential masking by subcutaneous tissue. The nurse should focus on areas with minimal pigmentation for accurate assessment.
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