- A home health nurse is planning care for an older adult client with mobility issues. Which task related to promoting home safety can the nurse delegate to an unlicensed assistive personnel (UAP)?
Answer: Assisting the client to remove clutter and secure loose area rugs on the floor.
When you encounter delegation questions on the NCLEX-RN, always consider the Five Rights of Delegation: right task, right circumstances, right person, right direction, and right supervision. The key principle is that nurses can delegate tasks that don't require nursing judgment, assessment, or teaching to unlicensed assistive personnel (UAP).
Assisting the client to remove clutter and secure loose area rugs (B) is the correct answer because this is a basic safety task that follows clear, established procedures. UAPs can perform concrete physical tasks like moving objects and securing rugs when given proper direction. This activity doesn't require clinical judgment about the client's condition or safety capabilities.
Let's examine why the other options require nursing expertise: Option A involves evaluating the client's functional abilities, which requires clinical assessment skills and professional judgment that only licensed nurses can provide. Option C requires developing a care plan and making clinical recommendations about medical equipment needs—this demands nursing knowledge of mobility assessments and therapeutic interventions. Option D involves patient education, which is always within the nurse's scope of practice since it requires clinical knowledge to identify hazards and teach safety principles effectively.
Remember this NCLEX strategy: UAPs can perform tasks that are routine, predictable, and don't change based on the client's clinical condition. If the task requires assessment, evaluation, teaching, or clinical decision-making, it stays with the nurse. Focus on whether the task needs nursing judgment—if yes, don't delegate it.
- The nurse performs a home assessment for an 80-year-old client with a history of falls who uses bifocal glasses. The nurse notes shiny waxed floors in the kitchen and the client wears socks when walking to the refrigerator. What is the PRIORITY action to ensure home safety?
Answer: Recommend non-skid footwear and avoid walking in socks on smooth floors
This question tests knowledge of home safety and fall prevention strategies for clients with vision corrections and fall history. The primary risk factor is wearing socks on shiny waxed floors, reducing traction and increasing slips. Recommending non-skid footwear is the priority action as it enhances stability on smooth surfaces. Option B improves vision but not traction; option C conserves energy but ignores flooring; option D identifies patterns but does not act. Decision-making focuses on footwear-floor interactions. Nurses must address immediate slip hazards. A transferable strategy is to evaluate floor surfaces and footwear in kitchen areas.
- A 67-year-old client is discharged home 2 days after a total knee replacement and will ambulate with a walker. In the home, the nurse notes a low coffee table in the main walking path, a bathroom without grab bars, and the client reports taking prescribed opioid pain medication that causes dizziness. What is the PRIORITY action to ensure home safety during the home visit?
Answer: Move the coffee table and clear a wide path for walker use from bedroom to bathroom.
Clearing the coffee table from the walking path is the priority because the route from the bedroom to the bathroom is currently obstructed for a client using a walker. The table is an immediate physical obstacle, and the opioid-induced dizziness makes tripping or falling even more dangerous. Teaching the client to rise slowly and hold the walker when dizziness occurs addresses medicine-related effects, but it leaves the table in the path and does not fix the environmental hazard. Discussing grab bars and a raised toilet seat is a strong long-term bathroom safety plan, but it is not the immediate action needed for the current pathway. Asking about pain level and dizziness timing is additional assessment after the nurse has already identified an obvious hazard; delaying the hazard removal while taking details is not appropriate. Once the walking path is clear, the other educational and home-modification plans can follow. The correct immediate action is to remove the coffee table and make the route safe for walker use.
- A home care nurse arrives for a visit and finds the client, an older adult, lying on the floor. The client is alert and states, "I tripped on the rug but I don't think I broke anything." What is the nurse's first action?
Answer: Instruct the client to remain still while performing a head-to-toe assessment for injury.
When you encounter a client who has fallen, your priority is always safety and thorough assessment before any movement. Falls in older adults can cause serious injuries that aren't immediately apparent, including head trauma, spinal injuries, or fractures that could be worsened by movement.
Option B is correct because you must first ensure the client remains still to prevent further injury, then conduct a systematic head-to-toe assessment. Even though the client feels fine and is alert, this doesn't rule out serious injury. Many fractures, particularly hip fractures common in older adults, may not cause severe immediate pain. Internal injuries or spinal trauma could also be present without obvious symptoms.
Option A is premature - calling EMS should only happen after your assessment reveals injuries requiring emergency care or if the client cannot be safely moved. Option C is dangerous because assisting the client to move before assessment could worsen undetected injuries, particularly spinal or hip fractures. Option D, while important, is not the immediate priority - assessment and ensuring safety come before documentation and communication.
Remember the principle "don't move until you prove it's safe." On NCLEX questions involving trauma or falls, always look for the answer that prioritizes thorough assessment while maintaining safety. The client's self-report of feeling fine should never override your professional assessment responsibilities, especially with older adults who may have decreased pain sensation or cognitive changes that affect their perception of injury.
- During a home health visit, the nurse assesses a 79-year-old client who lives alone and uses a cane due to osteoarthritis. The nurse notes loose throw rugs in the hallway, a dim lightbulb near the bathroom, and an extension cord stretched across the walking path. Which modification should the nurse recommend to reduce fall risk?
Answer: Remove the throw rugs and secure cords along the wall to keep walkways clear
This question tests knowledge of home safety and fall prevention strategies for older adults with mobility impairments. The primary environmental hazards are loose throw rugs, a dim lightbulb, and an extension cord across the walking path, which increase tripping risks for a client using a cane. Removing throw rugs and securing cords along the wall best reduces fall risk by eliminating tripping hazards and maintaining clear walkways. Option B is incorrect as limiting fluids may cause dehydration; option C delays intervention by focusing on history rather than immediate changes; option D is less effective as soft-soled slippers may increase slipping on smooth surfaces. Effective fall prevention prioritizes modifying the environment to address extrinsic risks like clutter and poor lighting. Nurses should collaborate with clients to implement simple, immediate changes that promote independence. A transferable strategy is to conduct a room-by-room walkthrough to identify and mitigate potential tripping hazards.
- The nurse completes a home visit for a 74-year-old client living alone with mild lower-extremity weakness who uses a walker. The client states, "I leave my walker by the door and hold onto furniture to get to the bathroom because it's faster." The nurse should QUESTION which client behavior?
Answer: Using furniture for support instead of using the walker to reach the bathroom
This question tests knowledge of home safety and fall prevention strategies for clients with lower-extremity weakness using assistive devices. The primary risk factor is the client's behavior of using furniture for support instead of the walker, which can lead to instability and falls. The nurse should question this behavior as it bypasses the prescribed assistive device, increasing fall risk. Option B reduces reaching hazards; option C promotes stability outdoors; option D minimizes bending risks. Fall prevention principles emphasize consistent use of assistive devices to maintain balance and support. Nurses must educate on proper techniques and discourage unsafe shortcuts. A transferable strategy is to observe client demonstrations of daily activities to identify improper habits.
- A nurse is preparing discharge instructions for an older adult client recovering from a hip fracture. The client lives in a two-story home. Which topic is the priority for the nurse to include in the home safety plan?
Answer: Arranging a temporary living space on the first floor to avoid using the stairs.
After a hip fracture, the most immediate and life-threatening risk is another fall. Climbing stairs places the greatest demand on balance and strength, so a fall on stairs could cause severe re-injury. Therefore, planning a temporary first-floor living space to eliminate stair use is the top priority. A balanced diet with calcium and vitamin D supports long-term bone health but does not address the immediate fall hazard. Checking for wound infection is important, but infections usually develop over days and are less urgent than preventing a fall. While an elevated toilet seat and shower chair reduce bathroom falls, the risk of falling on stairs is greater and more dangerous. Use prioritization: address the highest environmental risk first. This client needs to avoid stairs before other concerns.
- A nurse provides discharge teaching during a home visit for a 69-year-old client 3 days after cataract surgery who reports blurred vision in low light. The nurse notes the client's hallway has a burned-out bulb and the client keeps shoes and bags on the floor near the entry. Which finding indicates a need for INTERVENTION?
Answer: Burned-out hallway bulb resulting in poor lighting
This question tests knowledge of home safety and fall prevention strategies post-cataract surgery with vision changes. The primary environmental hazard is the burned-out hallway bulb causing poor lighting, which exacerbates blurred vision and tripping over items. This finding indicates a need for intervention as it directly impairs safe navigation. Option B is appropriate for vision; option C maintains routine; option D aids emergencies. Fall prevention involves ensuring adequate lighting to compensate for visual deficits. Nurses should address lighting immediately post-surgery. A transferable strategy is to verify illumination levels in transitional areas like hallways.
- A nurse is observing a client who had a left-sided stroke with resultant right-sided weakness using a cane for the first time. The nurse should intervene if the client performs which action?
Answer: Holds the cane using the right hand.
When you encounter questions about assistive devices like canes, focus on the fundamental principle: the cane should always be held on the client's strong side to provide maximum support and stability.
For a client with a left-sided stroke causing right-sided weakness, the left side remains strong. Therefore, the cane must be held in the left hand (the strong hand) to effectively support the weakened right side. This positioning allows the cane to bear weight when the weak leg steps forward, creating a stable tripod effect with both legs and the cane.
The correct answer is D because holding the cane with the right hand (the weak side) would provide inadequate support and create an unsafe walking pattern. The weakened right hand lacks the strength and coordination needed to properly control the cane.
Looking at the incorrect options: A is actually the correct technique—holding the cane with the left (strong) hand. B describes proper cane walking technique where the cane and weak leg advance together, allowing the cane to support the weakened limb. C shows appropriate cane fitting, as the handle should align with the hip joint or wrist level when the arm hangs naturally at the side.
NCLEX Strategy: Remember "strong side holds the cane" as your go-to rule. This principle applies whether the weakness is from stroke, fracture, or any condition causing unilateral weakness. Questions about assistive devices frequently test this fundamental safety concept, so master this pattern for guaranteed points.
- The nurse visits a 68-year-old client 1 week after hip surgery who uses a walker and reports waking at night to use the bathroom. The nurse notes the client keeps a phone charger cord stretched across the bedroom floor to reach the bed and the bedside lamp is out of reach. Which finding indicates a need for INTERVENTION?
Answer: A cord is stretched across the bedroom floor to the bed
This question tests knowledge of home safety and fall prevention strategies post-hip surgery for clients using walkers. The primary environmental hazard is the phone charger cord stretched across the bedroom floor, posing a tripping risk during nighttime bathroom trips. This finding indicates a need for intervention as it directly contributes to fall potential in a low-light setting. Option A reduces dehydration; option C ensures proper device use; option D improves traction. Decision-making involves identifying cords and poor lighting as common bedroom hazards. Nurses should recommend cord management to maintain clear floors. A transferable strategy is to check electrical setups in sleeping areas for entanglement risks.
- A home health nurse evaluates a 76-year-old client with diabetic peripheral neuropathy who reports decreased sensation in both feet. The nurse observes the client walking barefoot on hardwood floors and stepping over a low threshold between rooms. The nurse should QUESTION which client behavior?
Answer: Walking barefoot inside the home despite decreased foot sensation
This question tests knowledge of home safety and fall prevention strategies for clients with diabetic neuropathy affecting foot sensation. The primary risk factor is walking barefoot on hardwood floors, which can lead to undetected injuries or slips due to reduced sensation. The nurse should question this behavior as it increases fall and injury risks without protective footwear. Option B clears paths; option C improves visibility; option D promotes foot health monitoring. Fall prevention emphasizes appropriate footwear to compensate for sensory deficits. Nurses must educate on protective measures for neuropathic conditions. A transferable strategy is to evaluate flooring and footwear combinations in clients with sensory impairments.
- The nurse visits a 66-year-old client 2 days after discharge following total knee replacement who is using a front-wheeled walker and taking prescribed opioid pain medication. The home has a narrow path to the bathroom with cluttered magazines on the floor and no night-light; the client reports getting up at night to urinate. What is the PRIORITY action to ensure home safety?
Answer: Clear the pathway to the bathroom and add a night-light for nighttime ambulation
This question tests knowledge of home safety and fall prevention strategies post-surgery for clients on medications affecting balance. The primary risk factor is the cluttered pathway to the bathroom combined with nighttime ambulation while on opioids, which can cause dizziness. Clearing the pathway and adding a night-light best reduces fall risk by improving visibility and removing obstacles during high-risk times. Option A addresses dizziness but not environmental hazards; option C focuses on pain management, not safety; option D prevents clots but does not directly mitigate falls. Prioritizing environmental modifications is key in fall prevention, especially when intrinsic factors like medication side effects are present. Nurses must assess both client behaviors and home setup to tailor interventions. A transferable strategy is to simulate nighttime routines during assessments to uncover hidden hazards.
- During a home health visit, the nurse assesses an 82-year-old client who lives alone and uses a cane due to osteoarthritis. The client reports two near-falls this week; the hallway to the bathroom is dim, an extension cord crosses the walkway, and throw rugs are present. Which modification should the nurse recommend to reduce fall risk?
Answer: Remove throw rugs and secure or reroute the extension cord away from walkways
This question tests knowledge of home safety and fall prevention strategies for older adults at risk for falls. The primary environmental hazards identified are dim lighting, an extension cord crossing the walkway, and throw rugs - all significant trip hazards. Removing throw rugs and securing or rerouting the extension cord (B) best reduces fall risk by eliminating the most immediate physical obstacles in the client's path. While a flashlight (A) helps with lighting, it doesn't address the trip hazards; scheduling an eye exam (C) is important but not immediately actionable; and phone check-ins (D) don't address environmental hazards. The decision-making principle is to prioritize removing physical obstacles that pose immediate trip hazards before addressing other contributing factors. When assessing home safety, always identify and eliminate environmental hazards in high-traffic areas first, particularly pathways to essential areas like the bathroom.
- A home health nurse visits a 74-year-old client with mild cognitive impairment who lives with an adult daughter. The daughter reports the client wanders at night; the front door has a standard knob lock, the stairs lack a handrail, and medications are stored on the kitchen counter. Which finding indicates a need for INTERVENTION to reduce fall risk?
Answer: The stairs lack a secure handrail on one side
This question tests knowledge of home safety and fall prevention strategies for clients with cognitive impairment who wander. The primary risk factor is the lack of a secure handrail on the stairs, which poses a significant fall risk for any client, especially one with cognitive impairment who may wander at night. The stairs lacking a secure handrail (B) indicates a need for intervention because it creates a dangerous situation where the client could fall down the stairs, particularly when wandering in low light conditions. Medications on the counter (A) is more of a safety concern for accidental ingestion; well-fitting, nonskid shoes (C) are appropriate footwear that reduces fall risk; and drinking coffee (D) is not a fall risk. The decision-making principle is to identify structural hazards that pose the greatest risk of serious injury, with stairs being particularly dangerous for clients with cognitive impairment. When assessing homes of clients with cognitive impairment, prioritize securing areas where falls would result in the most severe injuries, such as stairs and bathrooms.
- A home health nurse visits a 75-year-old client with chronic obstructive pulmonary disease who uses oxygen and has tubing running from the concentrator to the bedroom. The nurse notes the tubing crosses a frequently used walkway to the bathroom. What is the PRIORITY action to ensure home safety?
Answer: Recommend securing oxygen tubing along the wall and keeping walkways clear
This question tests knowledge of home safety and fall prevention strategies for clients with respiratory conditions using oxygen. The primary environmental hazard is oxygen tubing crossing walkways, posing a tripping risk during bathroom trips. Recommending securing tubing and clearing walkways is the priority action as it prevents entanglement. Option A teaches breathing but ignores hazards; option C monitors but does not prevent; option D aids secretions but not safety. Decision-making focuses on equipment management in living spaces. Nurses must integrate medical devices into safe environments. A transferable strategy is to trace tubing paths for interference with movement.
- At a community health screening event, an RN speaks with a 79-year-old client who reports occasional lightheadedness when standing and one fall in the past year without injury. The client lives in an older home with a bathtub/shower combination and no nonslip surface, and uses reading glasses only. Which modification should the nurse recommend to reduce fall risk?
Answer: Install a nonslip mat or adhesive strips in the tub and use a shower chair if needed
This question tests knowledge of home safety and fall prevention strategies for older adults with orthostatic symptoms. The primary risk factor is the combination of lightheadedness when standing and a slippery bathtub surface, which significantly increases fall risk during bathing. Installing a nonslip mat or adhesive strips and using a shower chair (A) best reduces fall risk by providing stability and traction in the wet environment where falls are most likely. Limiting fluids (B) could lead to dehydration and worsen orthostatic hypotension; high-intensity unsupervised exercise (C) is dangerous for someone with balance issues; and wearing reading glasses while walking (D) would impair distance vision and increase fall risk. The decision-making principle is to address environmental hazards in areas where the client is most vulnerable, such as wet surfaces combined with position changes. When recommending home modifications, prioritize interventions that address both the environmental hazard and the client's specific risk factors, such as orthostatic symptoms in bathroom settings.
- A nurse provides family teaching for a 79-year-old client with moderate Alzheimer's disease who becomes agitated and tries to get up quickly when the doorbell rings. The family reports the client often trips over a small rug near the entryway. Which modification should the nurse recommend to reduce fall risk?
Answer: Remove the rug near the entryway and keep the entry path clear of items
This question tests knowledge of home safety and fall prevention strategies for clients with Alzheimer's disease and agitation. The primary environmental hazard is the small rug near the entryway, causing trips during sudden movements. Removing the rug and clearing the path best reduces fall risk by eliminating obstacles in response triggers. Option B adds hazards; option C restricts movement; option D delays action. Fall prevention involves minimizing triggers and hazards in dementia. Nurses should guide families on proactive changes. A transferable strategy is to identify agitation hotspots for environmental adjustments.
- A home care nurse visits a 70-year-old client recently discharged after abdominal surgery. The client reports needing to rush to the bathroom due to a new stool softener; the route includes a scatter rug at the bathroom doorway and a pet that often lies in the hallway. The nurse should QUESTION which client behavior?
Answer: Wearing loose slippers without backs to make it easier to slip shoes on quickly
This question tests knowledge of home safety and fall prevention strategies for post-surgical clients with urgency issues. The primary risk factor is the combination of rushing to the bathroom due to stool softeners and environmental hazards along the route. The nurse should question wearing loose slippers without backs (C) because they provide poor foot support and can easily slip off, increasing fall risk when hurrying to the bathroom. Keeping the pet in another room (A), removing the scatter rug (B), and using a night-light (D) are all appropriate safety measures that reduce fall risk. The decision-making principle is to identify unsafe behaviors that compound existing risk factors - loose footwear combined with rushing creates a dangerous situation. When assessing client behaviors, always evaluate whether their choices increase fall risk, particularly when combined with medication side effects or post-surgical recovery needs.
- A home health nurse visits a 71-year-old client recently discharged after abdominal surgery who reports feeling "a little unsteady" when standing. The nurse notes the client's bathroom has a slippery tub surface and no grab bars; the client plans to shower alone today. Which modification should the nurse recommend to reduce fall risk?
Answer: Install grab bars and use a non-slip mat or adhesive strips in the tub/shower
This question tests knowledge of home safety and fall prevention strategies in the bathroom for post-surgical clients with unsteadiness. The primary environmental hazard is the slippery tub surface without grab bars, heightening slip risks during showering. Installing grab bars and using non-slip mats or strips best reduces fall risk by providing support and traction in a wet environment. Option A is insufficient without internal tub modifications; option C may increase fall risk by reducing alertness; option D limits independence unnecessarily. Decision-making focuses on adaptive equipment to address slippery surfaces and weakness. Nurses should prioritize bathroom modifications as falls commonly occur there. A transferable strategy is to assess wet areas for traction and support features in all home evaluations.
- A home health nurse is visiting an 82-year-old client diagnosed with osteoporosis, mild cataracts, and hypertension treated with hydrochlorothiazide. The client lives alone. Which home safety instruction should the nurse prioritize?
Answer: Teach the client to change positions slowly, especially when rising from a sitting or lying position.
When you encounter a question about home safety for elderly clients with multiple conditions, you need to prioritize interventions based on which poses the greatest immediate risk for serious injury. This requires understanding how different medications and conditions interact to create safety hazards.
The correct answer is D because hydrochlorothiazide, a thiazide diuretic, commonly causes orthostatic hypotension as a side effect. When combined with the client's age (82 years old) and osteoporosis, falls from sudden blood pressure drops become extremely dangerous. A fall could result in hip fractures or other serious bone injuries that are potentially life-threatening in elderly patients. Teaching position changes addresses the most immediate and severe risk.
Option A, while beneficial for someone with cataracts, addresses vision issues that develop gradually and can be compensated for over time. The mild cataracts mentioned don't create an immediate emergency situation.
Option B targets general fall prevention, which is important but doesn't address the specific medication-related fall risk that poses the greatest immediate danger in this scenario.
Option C promotes good footwear choices for stability, but again doesn't target the primary risk factor - the medication side effect that can cause sudden falls even with proper shoes.
For NCLEX questions involving elderly clients with multiple conditions, always consider medication side effects first, especially when they interact with existing conditions like osteoporosis. Prioritize interventions that address the combination of factors creating the highest risk for serious injury or death.
