A nurse is providing discharge teaching to a client who is at risk for falls. Which of the following information should the nurse include in the teaching?
"Ensure carpeting on stairs is secured with tacks."
"Secure extension cords to the floor with paper tape."
"Place furniture in the hallway to hold onto when walking."
"Place a small rug on the floor next to the bathtub."
The Correct Answer is A
A. " Loose or uneven carpeting on stairs can increase the risk of falls for clients who have impaired balance or mobility. The nurse should instruct the client to secure carpeting on stairs with tacks or other fasteners to prevent slipping or tripping.
B. Securing extension cords with paper tape may not provide sufficient support and can pose a tripping hazard. It is better to use cable covers or secure them along the baseboard.
C. Placing furniture strategically in hallways increases the risk of falls. Furniture should be placed away from hallways.
D. Rugs in bathrooms can become slippery when wet, increasing the risk of falls. It is safer to use non-slip mats or rugs with rubber backing.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. A respiratory rate of 7/min is below the normal range and may indicate opioid- induced respiratory depression, which is a life-threatening complication requiring immediate intervention.
B. While important, a distended bladder does not pose an immediate threat to the client's life compared to respiratory depression.
C. Constipation is a common side effect of opioid medications but does not require immediate intervention unless accompanied by severe symptoms such as fecal impaction or bowel obstruction.
D. Pain management is important, but respiratory depression takes priority as it can lead to respiratory arrest and death.
Correct Answer is D,E,C,B,A
Explanation
A. Deep palpation is the final step in an abdominal examination since it may elicit tenderness which may interfere with other aspects of examination.
B. This is the second last step just before deep palpation. It is used to detect any obvious masses or areas of tenderness.
C. Percussion is the third step in an abdominal examination where the nurse should percuss the client's abdomen systematically, tapping lightly on each area and noting the sound quality. It can be used to detect the presence of ascites which be stony dull on percussion.
D. Inspection is the first step where the nurse should inspect the contours of the client's abdomen using a penlight, looking for any abnormalities or distension.
E. Auscultation is the second step in an abdominal examination. The nurse should auscultate the client's abdomen using the diaphragm of the stethoscope, listening for bowel sounds in all four quadrants.
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