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.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is D

Explanation

A. Occupational therapist: While occupational therapists may be involved in the client's care post-stroke to address functional abilities and activities of daily living, including feeding and meal preparation, they are not specifically trained to assess and treat swallowing disorders like a speech-language pathologist.

B. Physical therapist: Physical therapists focus on improving mobility, strength, balance, and coordination. While they play a crucial role in stroke rehabilitation, particularly in addressing gait and motor deficits, they are not typically involved in the assessment and treatment of swallowing disorders.

C. Social worker: Social workers provide support and resources to clients and their families to address psychosocial and practical concerns related to illness, disability, and rehabilitation. While they may be involved in the client's care for broader support needs, they are not specifically trained to address swallowing disorders like a speech-language pathologist.

D. Speech-language pathologist

A speech-language pathologist specializes in evaluating and treating communication and swallowing disorders. In this scenario, the client's coughing during swallowing indicates a potential swallowing disorder, known as dysphagia, which is common after a stroke. The speech-language pathologist is trained to assess the client's swallowing function, identify any impairments, and develop a treatment plan to improve swallowing safety and efficiency. They may recommend strategies and exercises to address the client's coughing and prevent complications such as aspiration pneumonia.

A. Ensure that the client's bed is in the lowest position. B. Assess skin temperature and color before applying the restraints. C. Attach the client's restraints toe bed rail. D. Pad bony prominences before applying the restraints. E. Secure restraints to allow three fingers to slide under the restraints

Correct Answer is ["A","B","D"]

Explanation

A. Ensure that the client's bed is in the lowest position.

Keeping the bed in the lowest position helps prevent injury if the client tries to get out of bed, especially when restrained.

B. Assess skin temperature and color before applying the restraints.

This action ensures proper circulation and skin integrity while the restraints are in use. It helps prevent skin breakdown and injury.

C. Attach the client's restraints to the bed rail.

Attaching restraints to the bed rail is not considered a best practice as it can increase the risk of injury to the client. Restraints should be secured to the bed frame or another stable part of the bed to minimize the risk of harm.

D. Pad bony prominences before applying the restraints.

Padding bony prominences such as elbows and wrists helps prevent pressure ulcers and discomfort caused by the restraints.

E. Secure restraints to allow three fingers to slide under the restraints.

Restraints should be secured to allow only two fingers to slide under the restraints to ensure they are not too loose or too tight.

View Question and Answer

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

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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who had a stroke and coughs frequently when swallowing. The nurse should identify that which of following members of the interdisciplinary team?

Correct Answer is D

Explanation

A nurse is planning care for a client who has a prescription for extremity restraints to both wrists. Which of the following actions should the nurse include in the plan of care? (Select all that apply.)

Correct Answer is ["A","B","D"]

Explanation

A nurse is planning to administer insulin to a client who has type 1 diabetes mellitus, what action should the nurse perform first?

A home health nurse is teaching a client about home safety. Which of the following statements by the client indicates an understanding of the teaching? (Select all that apply.)

A nurse is caring for a client who has influenza and isolation precautions in place. Which of the following actions should the nurse take to prevent the spread of infection?

A nurse is collecting a blood pressure (BP) reading from a client who is sitting in a chair. The nurse determines that the client's BP is 158/96 mm Hg. Which of the following actions should the nurse take?

A nurse in a clinic is teaching a client who has diabetes mellitus about self-administration of insulin using a prefilled, multidose pen. Which of the following instructions should the nurse include?

A community health nurse is visiting an older adult client who recently moved into an assisted living apartment. Which of the following client statements indicates difficulty accepting their transition?

A nurse is preparing to set up a sterile field. Which of the following actions should the nurse take?