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 B
Choice A rationale:
Retie the restraint straps with a slipknot. Rationale: If the restraints are too tight or uncomfortable for the client, adjusting them is essential. However, the slipknot is not the appropriate method. The nurse should ensure that the restraints are secure but not too tight, allowing for proper circulation and comfort for the client.
Choice B rationale:
Check that three fingers will fit beneath the restraints. Rationale: This is the correct action. The nurse should assess the tightness of the restraints by checking if three fingers can fit beneath them. This method ensures that the restraints are secure enough to prevent the client from removing them but not so tight that they compromise the client's circulation or skin integrity.
Choice C rationale:
Retie the restraint straps to the side rails. Rationale: Tying the restraints to the side rails is not a safe practice. It can cause injury to the client and is a restraint-related risk. Restraints should be tied to the bed frame, not the side rails, to ensure proper safety measures are followed.
Choice D rationale:
Remove the padding under the wrist restraints. Rationale: The padding under the wrist restraints provides comfort and prevents skin irritation. Removing the padding is not necessary unless it is soiled or damaged. The nurse should focus on ensuring that the restraints are appropriately secured and not causing harm to the client.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["0.397"]
Explanation
The correct answer is choice: 0.397.
To convert 397 mg to grams, the following calculation can be done: Understand the Conversion Factor: 1 gram (g) is equal to 1000 milligrams (mg) Therefore, to convert mg to g, divide the number of milligrams by 1000. 397 ÷ 1000 = 0.397. 397mg÷1000=0.397g Therefore,
397 mg is equal to 0.397 grams. .
Correct Answer is ["A","C"]
Explanation
Choice A rationale:
Instructing the clients to use the call light is an important action to prevent falls. If the clients need assistance or have to leave their beds, they should use the call light to alert the nurse or healthcare provider. Prompt response to call lights can prevent clients from attempting to move on their own and potentially falling.
Choice B rationale:
Keeping the clients' rooms dark is not a safe practice, especially for clients at risk for falls. Dim lighting can increase the risk of tripping or falling, especially during nighttime when visibility is already reduced. Adequate lighting in the clients' rooms is essential to ensure their safety.
Choice C rationale:
Moving overbed tables away from the bed is crucial in preventing falls. Overbed tables can obstruct the clients' movement, leading to accidents. By keeping the area around the bed clear, the clients have more space to maneuver safely, reducing the risk of falls.
Choice D rationale:
Performing client checks every 4 hours is a good practice, but it is not sufficient for clients at high risk for falls, especially during the night shift when they may need assistance to use the bathroom or move in bed. Frequent checks and availability to assist clients promptly are essential to prevent falls effectively.
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