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 ["A","C","E","F"]
Explanation
A. History of diabetes mellitus: This is correct. Diabetes mellitus can lead to delayed wound healing due to various factors, including impaired circulation, neuropathy, and compromised immune function.
B. Cholesterol level: While abnormal cholesterol levels can impact cardiovascular health, they are not directly linked to delayed wound healing unless they are part of a broader metabolic disorder or condition that affects vascular health.
C. Prealbumin level: Prealbumin is a marker of nutritional status. Low prealbumin levels can indicate malnutrition, which is a risk factor for delayed wound healing.
D. History of hyperlipidemia: Hyperlipidemia refers to high levels of fats (lipids) in the blood, such as cholesterol and triglycerides. While hyperlipidemia is associated with cardiovascular risk, it is not a direct risk factor for delayed wound healing unless it is part of a broader metabolic syndrome or condition affecting vascular health.
E. Mini Nutritional Assessment screening tool score: This is correct. The Mini Nutritional Assessment (MNA) screening tool assesses nutritional status, and a low score indicates malnutrition or nutritional deficiencies, which can contribute to delayed wound healing.
F. History of malnutrition: This is correct. Malnutrition, whether due to inadequate intake, absorption issues, or other factors, is a significant risk factor for delayed wound healing as it affects the body's ability to repair tissues and fight infection.
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.
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