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 D

Explanation

A. Move items in the room away from the client: During a seizure, the client may have uncontrolled movements that could cause them to hit nearby objects and potentially injure themselves. Moving items away from the client helps create a safer environment and reduces the risk of injury from contact with objects.

B. Loosen the client's clothing: Seizures can lead to muscle contractions and movements that might constrict the client's clothing, particularly around the neck or chest area. Loosening the client's clothing helps ensure that their breathing is not restricted during the seizure.

C. Turn the client onto their side: Turning the client onto their side is an important step for airway protection. During a seizure, there is a risk of saliva or vomit obstructing the airway, which can lead to aspiration. Turning the client onto their side helps prevent aspiration by allowing any fluids to drain out safely and maintaining an open airway.

D. Help the client lie on the floor: If the client is seated in a chair during a seizure, it's safer to assist them in lying on the floor. This action prevents the client from falling out of the chair and potentially sustaining injuries from the fall. Once on the floor, the nurse can continue to monitor the client and provide appropriate care and support.

A. Prepare the client for surgery. B. Contact the facility's ethics committee for guidance. C. Keep the client stable until a family member arrives to give consent. D. Obtain consent from the surgeon.

Correct Answer is A

Explanation

A. Prepare the client for surgery: In emergency situations, if immediate intervention is required to save the client’s life or prevent significant harm, the principle of implied consent may apply. This means that if the client is unconscious and immediate treatment is necessary, healthcare providers may proceed with treatment under the assumption that the client would consent if able. However, this should be done in accordance with facility policies and legal guidelines.

B. Contact the facility's ethics committee for guidance: Contacting the ethics committee can be helpful for guidance on how to handle consent issues in complex situations, but it might not provide a timely solution for immediate emergency situations.

C. Keep the client stable until a family member arrives to give consent: While stabilizing the client's condition is important, waiting for a family member to arrive to give consent may not be feasible in emergency situations where immediate treatment is necessary. The nurse should seek guidance from appropriate channels to determine the best course of action.

D. Obtain consent from the surgeon: Surgeons do not have the authority to provide consent for treatment on behalf of a client who is unconscious. Consent must come from a legally authorized decision-maker, such as the client themselves if they have previously provided informed consent, or a designated healthcare proxy.

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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

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Explanation

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