A night shift nurse works and cares for several clients at risk for falls.
Which of the following actions should the nurse take?
Instruct the clients to use the call light.
Keep the clients' rooms dark.
Move overbed tables away from the bed.
Perform client checks every 4 hours.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["473"]
Explanation
The correct answer is choice: 473.
To convert 4 ounces to milliliters (mL), the following steps can be taken:
Understand the Conversion Factor: 1 fluid ounce (oz) is approximately 29.57 mL. Therefore, 4 oz can be converted to mL using the following calculation: 4 × 29.57 = 118.28
4oz × 29.57mL/oz = 118.28mL.
Convert Cups to Ounces: 1 cup is equal to 8 fluid ounces.
Therefore, 1 cup is 8 × 29.57= 236.56
8oz × 29.57mL/oz = 236.56mL.
So, 1 cup is equal to 236.56 mL. The correct answer is 473 mL (2 cups)
Correct Answer is B
Explanation
Choice A rationale:
Obtaining the blood pressure first thing in the morning is not the most critical factor in accurately measuring blood pressure. Blood pressure can vary throughout the day due to various factors, and it is essential to use the appropriate technique and equipment at any time of the day.
Choice B rationale:
Using the appropriate size cuff for the client is crucial in obtaining an accurate blood pressure reading. If the cuff is too small, it can lead to falsely elevated blood pressure readings, while a cuff that is too large can result in falsely lowered readings. This is because cuff size affects the pressure applied to the artery during measurement.
Choice C rationale:
Ensuring that the client is relaxed and comfortable prior to obtaining the blood pressure is important but not the most critical factor. Anxiety or discomfort can temporarily elevate blood pressure, so it's essential to create a calm and comfortable environment for the client. However, using the correct cuff size is still more critical for accurate measurements.
Choice D rationale:
Removing clothing from the arms before obtaining blood pressure is not the most important action. While it is generally recommended to expose the client's arm for proper cuff placement, it is secondary to using the appropriate cuff size. The cuff should be placed directly on the skin or over a thin layer of clothing, but this step should not take precedence over cuff size selection.
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
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.