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 B

Explanation

A.An 18-gauge, 1-inch needle is too large for subcutaneous injections like heparin. Heparin is administered subcutaneously using a smaller needle (e.g., 25- or 27-gauge) to minimize tissue trauma.

B.Heparin should be injected into the subcutaneous tissue, typically in the abdomen, but at least 2 inches (5.1 cm) away from the umbilicus to avoid the rich vascular supply and reduce the risk of bleeding or bruising in this area.

C.Air bubbles should not be expelled from prefilled syringes of heparin because the air bubble ensures the full dose is delivered and helps prevent medication from leaking into the subcutaneous tissue, reducing bruising at the injection site. Prefilled syringes are designed with this in mind.

D.Massaging the injection site after administering heparin increases the risk of bruising and bleeding due to the anticoagulant effects of heparin. Gentle pressure may be applied to prevent bleeding, but massaging should be avoided.

A. Grab bars are installed in the shower. B. The hot water heater is set to 47° C (117° F). C. There is an area rug covering a tile floor. D. Prescriptions are stored in a medication organizer.

Correct Answer is C

Explanation

A. Grab bars are installed in the shower: Installing grab bars in the shower is a safety measure that helps prevent falls and assists the client in safely maneuvering in the bathroom. This finding indicates a safe environment and does not require intervention.

B. The hot water heater is set to 47°C (117°F): The hot water heater set at 47°C (117°F) poses a scalding risk, especially for older adults with decreased sensation or mobility issues. The recommended safe temperature for hot water heaters is typically below 49°C (120°F) to prevent burns. Therefore, the nurse should intervene to adjust the temperature to a safer level.

C. There is an area rug covering a tile floor.

Area rugs covering tile floors can pose a significant fall risk, especially for older adults with osteoporosis, who are more susceptible to fractures. The rug can slip or bunch up, leading to trips and falls. Therefore, the nurse should intervene to remove the area rug or secure it firmly to the floor to prevent accidents.

D. Prescriptions are stored in a medication organizer: Storing prescriptions in a medication organizer promotes medication adherence and organization, which is beneficial for older adults managing multiple medications. This finding indicates good medication management and does not require intervention.

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