A nurse is admitting a client who is at risk for falls to a medical-surgical unit. Which of the following actions should the nurse take?

Place the bedside table 0.9 m (3 feet) away from the bed.

Provide the client with a night light.

Elevate full-length side rails on both sides of the client's bed.

Keep the client's room temperature at 18° C (64.4° F).

Answer and Explanation

The Correct Answer is B

A. Place the bedside table 0.9 m (3 feet) away from the bed:

While having a bedside table nearby can be convenient for clients to access essential items, the specific distance of 0.9 m (3 feet) is not a standard guideline for falls prevention. Placing the bedside table closer to the bed may actually improve accessibility for the client, but it's not the most crucial action for falls prevention in this scenario.

B. Provide the client with a night light.

Falls prevention strategies aim to create a safe environment for clients at risk of falling. Providing a night light helps improve visibility during nighttime, reducing the risk of falls due to poor lighting. It assists clients in navigating their surroundings safely, especially when getting out of bed during the night.

C. Elevate full-length side rails on both sides of the client's bed:

Using full-length side rails on the bed can increase the risk of entrapment and injury, especially for clients at risk of falls. Current evidence suggests that the use of physical restraints, such as full-length side rails, does not effectively prevent falls and may contribute to adverse outcomes.

D. Keep the client's room temperature at 18°C (64.4°F):

While maintaining a comfortable room temperature is important for client comfort, the specific temperature of 18°C (64.4°F) is not a standard guideline for falls prevention. Instead, ensuring a comfortable temperature range based on individual client preferences and environmental factors is appropriate.

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Correct Answer is D

Explanation

A. "I will weigh myself once weekly."Clients with heart failure should weigh themselves daily to monitor for fluid retention. A sudden weight gain (e.g., 2-3 lbs in 24 hours or 5 lbs in a week) may indicate worsening heart failure and should be reported to the provider.

B. "I will take my new medication in the evening."Hydrochlorothiazide is a diuretic that increases urine output. Taking it in the evening can lead to nocturia and sleep disturbances. Instead, it should be taken in the morning to minimize nighttime urination.

C. "I will take a hot bath before going to bed."Hot baths can cause vasodilation, leading to a drop in blood pressure (orthostatic hypotension), which increases the risk of dizziness and falls, especially in older adults taking diuretics. A warm (not hot) bath is safer.

D. "I will leave a light on in my bathroom at night."Older adults, especially those taking diuretics like hydrochlorothiazide, are at increased risk for nocturia and falls due to frequent trips to the bathroom. Keeping a light on in the bathroom at night enhances visibility and reduces the risk of falls, which is a major concern in this population.

A. Avoid pinching the skin when injecting the needle. B. Use pen needles that have a safe-needle protection device attached. C. Use the dominant hand to recap the needle before removing it from the pen device. D. Remove the needle from the pen device before placing the needle in a sharps container.

Correct Answer is B

Explanation

A. Avoid pinching the skin when injecting the needle:

This instruction is not specific to the use of a prefilled, multidose pen for insulin administration. Pinching the skin may be necessary for some injection techniques but is not directly related to the use of a prefilled pen.

B. Use pen needles that have a safe-needle protection device attached.

Using pen needles with a safe-needle protection device attached ensures safe handling and disposal of the needle after use, reducing the risk of accidental needlestick injuries. These devices help prevent accidental needlesticks by covering the needle after use, reducing the risk of transmission of bloodborne pathogens.

C. Use the dominant hand to recap the needle before removing it from the pen device:

Recapping needles is not recommended as it increases the risk of needlestick injuries. Additionally, the use of the dominant hand for recapping is not essential and may not be safe practice.

D. Remove the needle from the pen device before placing the needle in a sharps container:

It's crucial to dispose of needles safely in a sharps container immediately after use without removing the needle from the pen device. Removing the needle before disposal increases the risk of needlestick injuries. The entire pen needle unit, including the needle, should be disposed of intact into an appropriate sharps container to minimize the risk of injury to healthcare workers and others handling the waste.

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A nurse is admitting a client who is at risk for falls to a medical-surgical unit. Which of the following actions should the nurse take?

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