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).
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Administer the client's insulin dose using a tuberculin syringe:
While using an appropriate syringe for insulin administration is important, ensuring the accuracy of the dosage precedes the actual administration. Therefore, verifying the dose takes precedence over selecting the syringe.
B. Use a filter needle when withdrawing medication from the multidose vial:
While using a filter needle can be beneficial to prevent contamination, ensuring the correct dosage is more critical in preventing adverse effects associated with incorrect insulin administration.
C. Verify the dose of insulin with another nurse once it is prepared.
Before administering insulin to a client with type 1 diabetes, it is essential to ensure accuracy in dosage. Verifying the dose with another nurse helps minimize the risk of errors, ensuring the client receives the correct amount of insulin. This step aligns with the principle of double-checking medications for safety, especially in critical situations like insulin administration.
D. Mix the client's long-acting and rapid-acting insulin dose in one syringe:
Mixing different types of insulin in one syringe is not standard practice unless specifically instructed by a healthcare provider. This step should be performed only if explicitly ordered an
Correct Answer is D
Explanation
A. "I've never been the kind of person to ask others for help":
This statement indicates that the client may still be struggling with accepting help from others, which suggests that they have not fully adapted to their new situational role. It reflects a reluctance to rely on others and may indicate a desire to maintain independence.
B. "I'm looking forward to being able to be independent again":
While this statement suggests a desire for independence, it does not necessarily indicate that the client has already adapted to their new situational role. It may reflect an aspiration or goal rather than a current state of adaptation.
C. "I really don't know what I'm supposed to do all day":
This statement suggests uncertainty and confusion about how to fill the day, which may indicate difficulty adjusting to the new living arrangement and role. It does not necessarily indicate adaptation but rather a sense of disorientation or discomfort with the current situation.
D. "It's nice having other people cook for me."
This statement suggests that the client has become comfortable with and is accepting of the support provided by their adult child, indicating an adaptation to their new situational role. By expressing appreciation for having others cook for them, the client demonstrates a willingness to rely on and accept assistance from their family member, which is an important aspect of adapting to changes in living arrangements and roles.
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.