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?

Elevate full-length side rails on both sides of the client's bed.

Place the bedside table 0.9 m (3 feet) away from the bed.

Provide the client with a night light.

Keep the client's room temperature at 18° C (64.4" F).

Answer and Explanation

The Correct Answer is C

A. Elevating full-length side rails on both sides of the client's bed is not recommended, as it can increase the risk of injury if the client tries to climb over them or gets trapped between them.

B. Placing the bedside table 0.9 m away is unrelated to fall prevention.
C. A night light can help the client see better in the dark and avoid tripping or falling over objects.
D. Maintaining the room temperature is important for comfort but doesn't directly prevent falls.

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Correct Answer is C

Explanation

A. Expressing a desire for independence indicates the client may not have fully adapted to relying on others yet.
B. Reluctance to ask for help suggests the client is still adjusting and may not have fully embraced the new living arrangement.
C. Expressing enjoyment or appreciation for others cooking for them indicates acceptance of assistance and adaptation to the new living situation.
D. Expressing uncertainty about daily activities suggests a lack of adjustment to the new environment and situation.

A. Massage the client's bony prominences. B. Ensure the client's heels are not touching the mattress. C. Raise the head of the client's bed to a 60° angle. D. Reposition the client every 4 hr.

Correct Answer is B

Explanation

A. Massaging bony prominences can actually increase the risk of pressure injury by causing friction and shearing forces on the skin.
B. Elevating the heels reduces the pressure on the skin and improves blood circulation.
C. Raising the head of the bed to a 60° angle doesn't directly address pressure injury prevention and might even increase pressure on certain areas.
D. Repositioning the client every 4 hours is not frequent enough to prevent pressure injuries.

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