The nurse is monitoring for risk for injuries identified in the healthcare environment. Which unsafe healthcare environment finding(s) will require action from the nurse? Select all that apply

Frayed electrical cords

Call light within reach for all clients

Light bulbs burnt out in client rooms

Client rooms that are clear of debris

Alarms not functioning properly

Hallways cluttered with equipment and beds

Answer and Explanation

Correct Answer : A,C,E,F

A. Frayed electrical cords: Frayed cords pose a serious risk of electrical shock or fire. The nurse must report and ensure repair or replacement immediately to maintain a safe environment for both clients and staff.

B. Call light within reach for all clients: Having the call light accessible promotes client safety and independence. This is a safe practice and does not require corrective action.

C. Light bulbs burnt out in client rooms: Burnt-out light bulbs can lead to poor visibility, increasing the risk of trips, falls, and other accidents. The nurse should ensure that lighting is restored promptly to maintain a safe environment.

D. Client rooms that are clear of debris: Clear rooms reduce fall risks and support a safe environment. This indicates proper housekeeping and does not require intervention.

E. Alarms not functioning properly: Nonfunctioning alarms, such as bed or chair alarms, compromise patient safety by preventing timely alerts for at-risk clients. The nurse must have these repaired or replaced immediately.

F. Hallways cluttered with equipment and beds: Cluttered hallways obstruct safe movement, creating fall hazards and delaying emergency responses. Immediate action is needed to clear pathways and maintain safety standards.

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Correct Answer is D

Explanation

A. Request that handouts be prepared for the client: While handouts can supplement teaching, simply providing written materials may not ensure understanding, especially if the client has limited literacy or language proficiency. Handouts alone are insufficient for accurate comprehension.

B. Provide information with graphics and photographs: Visual aids can enhance understanding, but they may not fully convey complex medical information or instructions. Relying solely on visuals can lead to misinterpretation without proper translation.

C. Ask a family member to translate instructions: Using a family member for translation can risk inaccurate or incomplete communication and may compromise confidentiality. Medical terminology may be misunderstood, which can affect safe care.

D. Use a trained medical interpreter for translation: A trained medical interpreter ensures accurate, culturally appropriate communication and helps the client fully understand the teaching. This approach supports informed decision-making and patient safety.

A. Covid-19 vaccine received in 2020 B. Cholecystectomy in 2017 C. Nausea after meals D. Skin color is appropriate to ethnicity with pink undertones E. Headache, rated as a 4 on a 0-10 scale F. Blood pressure 112/76 mmHg

Correct Answer is {"A":{"answers":"A"},"B":{"answers":"A"},"C":{"answers":"A"},"D":{"answers":"B"},"E":{"answers":"A"},"F":{"answers":"B"}}

Explanation

• Covid-19 vaccine received in 2020: Vaccination history is obtained through interview questions about past immunizations. It cannot be observed or measured during the physical exam, making it part of the health history.

• Cholecystectomy in 2017: Surgical history is collected via client interview. The nurse relies on the client’s report or medical records rather than physical observation for this information.

• Nausea after meals: Nausea is a subjective symptom experienced by the client and must be reported during the health history. It cannot be directly observed during the physical exam.

• Headache, rated as a 4 on a 0-10 scale: Pain intensity is subjective and gathered from the client during the history interview. Numeric pain ratings reflect personal experience, not objective measurements.

• Skin color is appropriate to ethnicity with pink undertones: Skin color is observed directly during the physical assessment. Visual inspection allows the nurse to evaluate for pallor, cyanosis, or other abnormalities.

• Blood pressure 112/76 mmHg: Blood pressure is an objective measurement obtained using a sphygmomanometer during the physical exam. It reflects the client’s current physiological status.

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The nurse is monitoring for risk for injuries identified in the healthcare environment. Which unsafe healthcare environment finding(s) will require action from the nurse? Select all that apply

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse educates a client with limited English-speaking skills about their disease. What action should the nurse take to ensure the client is able to understand the teaching?

Correct Answer is D

Explanation

The nurse is evaluating the client's assessment within their electronic health record. For each finding, click to specify whether the assessment finding was collected as part of the health history interview or the physical exam.

Correct Answer is {"A":{"answers":"A"},"B":{"answers":"A"},"C":{"answers":"A"},"D":{"answers":"B"},"E":{"answers":"A"},"F":{"answers":"B"}}

Explanation

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A nurse is completing an assessment. Which should the nurse assess using inspection?

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