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 C

Explanation

A. Placing wet towels along the base of the door: While this action may help prevent smoke from entering or exiting the room, it is not the immediate priority. Activating the fire alarm takes precedence to alert others to the fire and initiate the appropriate response.

B. Turning off any electrical equipment: While turning off electrical equipment can reduce the risk of electrical fires, it is not the immediate priority. Activating the fire alarm is the first step to ensure the safety of everyone in the facility.

C. Activate the facility's fire alarm.

Activating the fire alarm is crucial because it immediately alerts others in the facility to the presence of a fire, enabling them to respond appropriately. This action initiates the facility's fire safety protocols, including evacuating the area and summoning professional assistance to extinguish the fire. The sooner the alarm is activated, the quicker the response can be, reducing the risk to individuals and property.

D. Directing a fire extinguisher at the fire: While using a fire extinguisher may be necessary to extinguish the fire, it should only be done after activating the fire alarm to ensure that emergency personnel are alerted and responding to the situation.

A. Eyewear B. Gloves C. Mask D. Gown

Correct Answer is B

Explanation

A. Eyewear: Eyewear, such as goggles or a face shield, should be removed after the mask. Eyewear protects the eyes from exposure to infectious respiratory droplets or aerosols. When removing eyewear, the nurse should handle it by the sides and avoid touching the front surface, which may be contaminated.

B. Gloves: Gloves are the first item to be removed when leaving the client's room. This is because gloves are in direct contact with potentially contaminated surfaces or materials. Removing gloves first helps prevent the spread of pathogens from the gloves to other parts of the PPE or the nurse's skin.

C. Mask: After removing gloves, the nurse should remove the mask next. Masks are worn to protect the respiratory system from inhaling airborne infectious particles. When removing the mask, it's important to handle it by the straps or ties and avoid touching the front surface, which may have been exposed to pathogens.

D. Gown: The gown is the last item to be removed. Gowns provide coverage to protect clothing and skin from contamination. When removing the gown, it's important to do so carefully to avoid contaminating oneself or the surrounding environment.

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