A nurse is reinforcing teaching about home safety for a client who has a history of falls.
Which of the following statements should the nurse identify as an indication that the client understands the instructions?
"I will keep my walker at the end of my bed.".
"I will keep the fluorescent ceiling light on in my room at night.".
"I will place an area rug at the entry of my bathroom.".
"I will place a bath seat in my shower to use when I bathe.". .
The Correct Answer is D
The correct answer is Choice D.
Choice A rationale: Keeping the walker at the end of the bed is inconvenient and increases the risk of falls. The walker should be easily accessible, ideally placed near where the client gets up from bed, to provide immediate support.
Choice B rationale: Fluorescent ceiling lights can be too harsh and cause glare, making it difficult for the client to see properly at night. Instead, using a nightlight or a softer, dimmable light source is recommended to provide safe, clear visibility.
Choice C rationale: Placing an area rug at the entry of the bathroom poses a tripping hazard. Loose rugs can easily shift and cause falls. It's better to use non-slip mats or secure carpeting to ensure safe footing, especially in areas prone to moisture.
Choice D rationale: Using a bath seat in the shower reduces the risk of slipping and falling. It provides a stable and secure place to sit while bathing, which is particularly important for clients with a history of falls or limited mobility.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale:
The anterior surface of the drape is not the correct choice because it includes the central sterile area, which should never be touched by the nurse. Touching the central sterile area contaminates the field.
Choice B rationale:
The outer 1-inch border of the drape is the correct choice for the nurse to touch. This border is considered non-sterile and can be handled without contaminating the sterile field. It acts as a barrier, preventing contaminants from reaching the central sterile area.
Choice C rationale:
The top inner corners of the drape are part of the central sterile area and should not be touched by the nurse. Touching this area would contaminate the sterile field.
Choice D rationale:
The posterior aspect of the drape is not the correct choice because it is part of the central sterile area. Touching this area would contaminate the sterile field. When preparing a sterile field, it is essential for the nurse to follow strict aseptic techniques to maintain the sterility of the field. This includes touching only the designated non-sterile areas, such as the outer 1-inch border of the sterile drape, to avoid contamination.
Correct Answer is A
Explanation
Choice A rationale:
The client's respirations are faster and deeper than normal due to expelling too much carbon dioxide. This condition is known as hyperventilation. Hyperventilation can occur due to various reasons such as anxiety, pain, fever, or metabolic acidosis. When the body expels excessive carbon dioxide, it leads to respiratory alkalosis, resulting in faster and deeper breathing to compensate for the decrease in carbon dioxide levels in the blood.
Choice B rationale:
This option is incorrect. Hypoxemia, or low blood oxygen levels, typically leads to rapid, shallow breathing (tachypnea) rather than deep and fast respirations.
Choice C rationale:
This option is incorrect. Inflammation of the phrenic nerve does not directly affect the depth and rate of respirations. Phrenic nerve inflammation is more likely to cause pain during breathing or hiccups.
Choice D rationale:
This option is incorrect. Using intercostal muscles to breathe is a normal physiological process, especially during deep or labored breathing. However, it does not explain the specific situation described in the question, where the respirations are faster and deeper than normal.
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