A charge nurse is observing a newly licensed nurse care for a client who is at risk for falls. Which of the following findings should the nurse identify as a risk factor for falls?
Positions the bedside table close to the client
Keeps the client's bed in the low position
Attaches the call light to the side rail of the client's bed
Instructs the client to wear their own socks to the bathroom
The Correct Answer is D
Choice A: This is incorrect because positioning the bedside table close to the client can help them reach their personal items and reduce the need to get out of bed.
Choice B: This is incorrect because keeping the client's bed in the low position can prevent injuries in case of a fall and make it easier for the client to get in and out of bed.
Choice C: This is incorrect because attaching the call light to the side rail of the client's bed can ensure that the client can access it easily and call for assistance when needed.
Choice D: This is correct because instructing the client to wear their own socks to the bathroom can increase the risk of slipping and falling. The client should wear non-skid footwear or slippers when walking.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A reason: Taking the medication right before eating breakfast is not an appropriate instruction, as it can reduce the absorption and effectiveness of alendronate, which is a bisphosphonate drug that inhibits bone resorption and increases bone density. The client should take the medication at least 30 min before eating or drinking anything other than water.
Choice B reason: Drinking milk with the medication is not an appropriate instruction, as it can interfere with the absorption and effectiveness of alendronate, which can bind to calcium and other minerals and form insoluble complexes that are excreted in feces. The client should avoid consuming dairy products or supplements that contain calcium, iron, magnesium, or aluminum for at least 30 min after taking the medication.
Choice C reason: Staying upright for 30 to 60 min after taking the medication is an appropriate instruction, as it can prevent esophageal irritation or ulceration that can be caused by alendronate, which can be corrosive to the mucosa if it remains in contact with it for too long. The client should not lie down or bend over until after their first food of the day.
Choice D reason: Chewing the tablets thoroughly is not an appropriate instruction, as it can increase the risk of esophageal irritation or ulceration that can be caused by alendronate, which can be abrasive to the mucosa if it is not swallowed whole with a full glass of water. The client should not crush, break, or dissolve the tablets in any liquid.
Correct Answer is D
Explanation
Choice A reason: Shaving the client from axillae to groin is not necessary, as it has no relation to the procedure and can cause skin irritation or infection.
Choice B reason: Administering a cleansing enema is not required, as it does not affect the upper gastrointestinal tract that is examined by the procedure. The client should fast for at least 6 hours before the procedure to ensure an empty stomach.
Choice C reason: Having the client drink contrast medium is not indicated, as it can interfere with the visualization of the mucosa and lesions by the endoscope. The client may receive a local anesthetic spray or gargle to numb the throat and a sedative to relax and reduce discomfort during the procedure.
Choice D reason: Ensuring the signed consent is in the medical record is an essential action, as it indicates that the client has been informed about the purpose, risks, benefits, and alternatives of the procedure and has agreed to undergo it voluntarily.
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