How it Works
Try Naxlex NCLEX-RN (Free-Trial)

A night shift nurse works and cares for several clients at risk for falls.
Which of the following actions should the nurse take?

A.

Instruct the clients to use the call light.

B.

Keep the clients' rooms dark.

C.

Move overbed tables away from the bed.

D.

Perform client checks every 4 hours.

Answer and Explanation

The Correct Answer is A

 

The correct answer is A. Instruct the clients to use the call light.

 

Choice A rationale:

Instructing clients to use the call light ensures they can request assistance before getting up, which is a key strategy in preventing falls, especially during the night when visibility is reduced and the risk of disorientation is higher.

 

Choice B rationale:

Keeping the clients' rooms dark can increase the risk of falls as it makes it difficult for clients to see obstacles and navigate their environment safely. Adequate lighting is important for fall prevention.

 

Choice C rationale:

Moving overbed tables away from the bed can actually make it harder for clients to reach essential items and might increase the risk of falls if clients have to stretch or lean awkwardly to get what they need. The overbed table should be positioned within easy reach.

 

Choice D rationale:

Performing client checks every 4 hours is not frequent enough to effectively monitor at-risk clients. More frequent checks, such as hourly, are recommended to ensure safety and promptly address any needs that could prevent a fall.


Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Free Nursing Study Resources

Related Questions

Correct Answer is C

Explanation

The correct answer is C. Tuberculosis.

Choice A rationale:

Scabies is a skin infestation caused by mites, and it does not require airborne precautions. Standard precautions, such as gloves and hand hygiene, are sufficient.

Choice B rationale:

Mycoplasmal pneumonia is typically spread through droplets, and a regular surgical mask is usually adequate for protection.

Choice C rationale:

Tuberculosis (TB) is an airborne disease, and healthcare workers need to wear an N95 respirator to protect themselves from inhaling the bacteria.

Choice D rationale:

Scarlet fever is spread through respiratory droplets, but it does not require airborne precautions. Standard precautions are usually enough.

Correct Answer is D

Explanation

Choice B rationale:

Call for additional staff to assist with the transfer. The nurse's priority in this situation is ensuring the safety of the client during the transfer from the chair to the bed. Calling for additional staff provides the necessary support to safely move the client, minimizing the risk of falls or injuries. It is crucial to have an adequate number of staff members to assist in transfers, especially when the client's mobility is compromised.

Choice A rationale:

Obtain a walker for the client to use to transfer back to bed. While a walker can be helpful for mobility, the client has already asked to return to bed, indicating the immediate need for assistance. Waiting to obtain a walker could delay the transfer, potentially putting the client at risk.

Choice C rationale:

Use a transfer belt and assist the client back into bed. Using a transfer belt is a suitable technique for assisting clients with mobility. However, the nurse's priority in this scenario is to ensure there is enough staff assistance to guarantee a safe transfer. The nurse should not attempt to perform the transfer alone, even with a transfer belt, as it might be unsafe for both the nurse and the client.

Choice D rationale:

Determine the client's ability to help with the transfer. While assessing the client's ability to participate in the transfer is important, it is not the nurse's priority in this situation. The immediate concern is to secure adequate assistance to safely move the client back to bed.

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

Register