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NCLEX RN Exam Prep about Safety Accident Injury and Error Prevention
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NCLEX RN Exam Prep about Safety Accident Injury and Error Prevention
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1 . The charge nurse is observing nursing staff. In which activity illustrated should the chargenurse intervene because it places the nurse most at risk for back injury?
ANSWER: D
A. The nurse is using a mechanical lift to move the client. Because another person is not present to
assist, there is a perceived increased risk for injury to the client.
B. Ambulating the client with a transfer belt increases the nurse’s risk for a back injury should the
client fall, but it is less of a risk than the twisting and bending illustrated in activity D.
C. The nurse is using a standing assist device to help the client move from a sitting to a standing
position and vice versa. Using assistive devices minimizes the risk for injury to the client and
nurse.
, D. Bending and twisting the torso can cause back injury if the nurse does not use correct body
mechanics. The nurse has reduced the risk by using a transfer belt and proper body mechanics,
but the risk for injury exists because the client could easily grab the nurse’s shoulder or arm with
his left hand, altering the nurse’s stance.
2. The client with a left-sided weakness is to be discharged to home, where the client has an
electrical bed. In preparation for discharge, the nurse assesses the client’s ability to get out
of bed independently- Which client actions indicate that further instruction is needed? Select
all that apply.
A. Places the bed in the lowest position
B. Raises the head of the bed (HOB)
C. Rolls onto the left side
D. Pushes against the mattress with the weak elbow and stronger hand to rise to a sitting position
E. Slides legs off the bed while pushing against the mattress to raise the body off the bed
F. Once in a sitting position, sits at the edge of the bed for a few minutes before standing
ANSWER: C, D
A. A low bed position prevents a fall from the feet not touching the floor.
B. Raising the I-IOB decreases the distance to a sitting position.
C. With a left-sided weakness, the client should turn onto the stronger side. which would be the
right and not the left side. Further instruction is needed.
D. The stronger (not weaker) elbow, hand, and leg should be used to push off from the bed into a
sitting position. Further instruction is needed.
E. The weight of the legs dangling will decrease the effort required to push into a sitting position.
F. Sudden position changes can cause orthostatic hypotension. Sitting awhile assures that the
client is not dizzy prior to standing.
3. The nurse documents in the client’s medical record: “Client uses a three-point gait
correctly to maintain non—weight-bearing on left foot when ambulating with emtehes.
Maintains steady balance and keeps eyes focused ahead.” On the illustration, place an X in
the tripod position box in the column that most accurately illustrates the gait documented by
the nurse.
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