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 D

Explanation

A. Urinary catheter care might be important but is less urgent than maintaining airway patency through endotracheal suctioning.
B. Enteral feeding is important for nutrition, but it's not as immediately critical as managing the client's airway.
C. Wound irrigation is important for wound care but takes precedence after addressing immediate airway concerns.
D. Endotracheal suctioning is crucial for maintaining a patent airway and takes priority due to its impact on breathing and oxygenation.

A. Two-point alternating gait B. Four-point alternating gait C. Swing-through gait D. Three-point gait

Correct Answer is D

Explanation

A. Two-point alternating gait involves partial weight-bearing on both legs and wouldn’t suit a client who can bear weight on only one leg.
B. Four-point alternating gait involves walking by moving one crutch followed by the opposite leg and is not suitable for a person who can bear weight on just one leg.
C. Swing-through gait involves swinging both legs forward between the crutches, typically used for individuals who have little or no weight-bearing ability.
D. Three-point gait involves bearing weight on one leg while using crutches and moving the other leg forward, the most appropriate gait for someone who can bear weight on one leg.

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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?

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