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 A
Explanation
Choice A rationale:
Standard precautions, as established by the Center for Disease Control (CDC), are to be used for any client, regardless of whether an infection has been identified. This means that healthcare providers, including nurses, must apply standard precautions in the care of all patients to prevent the spread of infections. The rationale behind this choice is based on the fundamental principle of infection control: it is not always possible to identify patients who may be carrying harmful pathogens. Some patients may not show visible signs of infection or may be in the incubation period of a disease, during which they are contagious but not symptomatic. Therefore, applying standard precautions universally helps to create a safe healthcare environment for both patients and healthcare providers. Standard precautions include practices such as hand hygiene, the use of personal protective equipment (PPE) like gloves and masks, safe injection practices, and respiratory hygiene.
Choice B rationale:
This choice incorrectly specifies the mode of transmission for using standard precautions. Standard precautions are not limited to cases where the infection is transmitted on air currents. Airborne precautions are used for diseases that spread via small droplets in the air, such as tuberculosis and measles. Standard precautions, on the other hand, cover a broader range of infections and are applied to all patients.
Choice C rationale:
This choice incorrectly narrows down the usage of standard precautions to cases where the infection spreads via moist droplets. While it is true that standard precautions include measures to prevent the transmission of infections through respiratory droplets, they are not limited to this mode of transmission. Standard precautions encompass various modes of transmission, including contact with blood and other body fluids, as well as contact with contaminated surfaces or items.
Choice D rationale:
This choice wrongly states that standard precautions are only used when there is an infection spread by indirect contact with an organism. Standard precautions include both direct and indirect contact with patients and their environment. It is not limited to specific types of infections or modes of transmission.
Correct Answer is C
Explanation
Choice A rationale:
This option is incorrect. Counting a regular pulse for 30 seconds and doubling the number is an appropriate method for assessing heart rate, not peripheral pulses. When assessing peripheral pulses, it is important to count the pulses directly for a full minute to accurately determine the pulse rate. This ensures that any irregularities or variations in the pulse rate are captured.
Choice B rationale:
This option is incorrect. Palpating the femoral artery in the groin is a standard method for assessing peripheral pulses. It is not a safety issue when performed correctly. However, the question asks about a safety issue related to assessing peripheral pulses.
Choice C rationale:
Palpating both carotid pulses at the same time is a safety issue when assessing peripheral pulses. Simultaneously palpating both carotid pulses can lead to excessive pressure on the carotid sinuses, which are baroreceptors located in the carotid arteries. Stimulation of these baroreceptors can result in a reflex decrease in heart rate and blood pressure, leading to a condition known as carotid sinus hypersensitivity. This can cause dizziness, fainting, or, in extreme cases, cardiac arrest. Therefore, it is essential to avoid palpating both carotid pulses simultaneously to prevent adverse reactions in clients, especially those with cardiovascular issues.
Choice D rationale:
Palpating the radial artery on the thumb side of the wrist is a standard method for assessing peripheral pulses. It is a safe and commonly used technique for evaluating radial pulse rate, rhythm, and amplitude. .
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