A nurse in a long-term care facility is admitting a client who has occasional urinary incontinence. To adhere to The Joint Commission's National Patient Safety Goals, which of the following actions should the nurse plan to take?

Keep the client's bed in its highest position with the side rails up.

Provide adult diapers for the client to wear while in bed.

Store the client's personal possessions in the closet in her room.

Ask the client to give a return demonstration of how to use the call light.

Answer and Explanation

The Correct Answer is D

A. Keep the client's bed in its highest position with the side rails up. Keeping the bed in its highest position increases the risk of falls, especially for a client with urinary incontinence who may attempt to get up quickly. This does not adhere to safety guidelines.
B. Provide adult diapers for the client to wear while in bed. While providing diapers may be necessary, it is not the primary safety intervention. It is more important to address the client's mobility and ensure they can safely access the bathroom.
C. Store the client's personal possessions in the closet in her room. Keeping the room tidy and ensuring personal items are stored safely can reduce clutter and fall risks but does not directly address incontinence management or safety goals.
D. Ask the client to give a return demonstration of how to use the call light. Ensuring the client knows how to use the call light is crucial for safety. It allows them to call for assistance when needed, reducing the risk of falls when they need to use the bathroom.

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Correct Answer is D

Explanation

A. "Why don't I get the chaplain to come and pray with you?" This response might make the client feel dismissed.
B. "I'll come back at a time when I can spend more time with you." This does not address the client's immediate need for spiritual support.
C. "Maybe it would be better if we read a passage from the Bible." Assuming the client wants to read the Bible may not be appropriate.
D. "Do you have a preference about how we pray together?" This response shows respect for the client's spiritual needs and preferences.

A. Install a bed exit sensor pad at the foot of the client's bed. B. Encourage the client to ambulate in compression stockings. C. Raise all four side rails for the client at bedtime. D. Place a raised toilet seat in the client's bathroom.

Correct Answer is D

Explanation

A. Install a bed exit sensor pad at the foot of the client's bed. While a bed exit sensor pad can be useful, it is typically placed on the mattress near the client's hips or lower back, not at the foot of the bed. This placement ensures it detects movement when the client tries to get up, thereby alerting staff to provide assistance.
B. Encourage the client to ambulate in compression stockings. Compression stockings can help with circulation but do not directly address fall prevention. Additionally, they can be slippery on some surfaces, potentially increasing the risk of falls if proper footwear is not used.
C. Raise all four side rails for the client at bedtime. Raising all four side rails is considered a form of restraint and can increase the risk of injury if the client attempts to climb over them. It can also limit the client’s ability to get out of bed independently and safely.
D. Place a raised toilet seat in the client's bathroom. This intervention is appropriate for fall prevention. A raised toilet seat can help clients with mobility issues by making it easier to sit down and stand up, thereby reducing the risk of falls in the bathroom, which is a common site for falls.

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A nurse in a long-term care facility is admitting a client who has occasional urinary incontinence. To adhere to The Joint Commission's National Patient Safety Goals, which of the following actions should the nurse plan to take?

Nursing Test Bank

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