Difficulty: Medium
Average Score: 92%
Simulated
A nurse on a medical-surgical unit is caring for a group of clients. Which of the following findings should the nurse identify as a safety hazard?
Correct answer
D
Rationale
Raising all four side rails of a client's bed is a safety hazard because it increases the risk of injury if the client tries to climb over them. It also restricts the client's mobility and may cause feelings of isolation and imprisonment. It is a violation of the client's rights and dignity. A weight-sensitive sensor mat is a safety measure to prevent falls, a buzzing sensation from a TENS unit is expected, and a capillary refill of less than 2 seconds indicates good perfusion.