A home health nurse is conducting a home inspection for a client who is at risk for falls. Which of the following instructions should the nurse provide for the client?

Place the bedside table 2 feet away from the bed.

Move the client's bed to the main floor of the house.

Keep lighting in the home dim.

Place area rugs on slick floor surfaces.

Answer and Explanation

The Correct Answer is B

A.   Incorrect. The bedside table should be within easy reach of the bed to prevent the client from attempting to reach for items and potentially falling.
B.   Correct. Moving the client's bed to the main floor of the house reduces the need for using stairs, which can be a fall risk for clients at risk for falls.
C.   Incorrect. Keeping the lighting dim increases the risk of falls. Adequate lighting is important to prevent falls.
D.   Incorrect. Area rugs on slick floor surfaces can be hazardous and increase the risk of falls.
They should be removed or secured properly.

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Correct Answer is B

Explanation

A.Restraints should be released more frequently, typically every 2 hours, to assess circulation, skin integrity, and range of motion, and to provide an opportunity for toileting and other needs.

B.It is essential to document the specific behaviors that led to the use of restraints, as this provides a clear rationale for why the restraints were necessary. This documentation is important for legal and clinical reasons and helps ensure that restraints are used appropriately and only when absolutely necessary.

C.Clients are not required to provide written consent for the use of restraints, especially in situations where restraints are necessary to protect the client or others from immediate harm. However, the nurse must follow the facility's protocol, which usually involves obtaining a physician's order and documenting the justification for the restraint use.

D.The nurse should check the client's status more frequently, typically every 15 minutes, to ensure the client's safety and well-being while in restraints.

A. Reduced fat in the stools B. Improved absorption of vitamins B and C C. Improved respiratory function D. Decreased sodium excretion

Correct Answer is A

Explanation

A. Correct. Pancre-lipase is an enzyme replacement therapy used in cystic fibrosis to improve digestion and absorption of fats. Reduction in fat in the stools indicates improved fat digestion.
B. Improved absorption of vitamins B and C might occur as a result of improved overall digestion, but it is not the primary therapeutic effect of pancre-lipase.
C. Improved respiratory function is not a direct effect of pancre-lipase.
D. Decreased sodium excretion is not a primary therapeutic effect of pancre-lipase.

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