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 A

Explanation

A. Eyelashes that curl slightly outward is a normal finding.
B. Eyelids that blink involuntarily 30 to 35 times per minute may be a normal range, but it's not typically assessed during a routine eye examination.
C. Pupils of 8 to 9 mm in diameter might indicate dilation, which is not a normal finding during a regular eye assessment.
D. Corneas with an opaque appearance could indicate issues such as corneal edema or opacity, which are abnormal findings.

A. Assist the client with a bowel cleansing B. Ensure the client is free of metal objects C. Administer 240 ml of oral contrast before the procedure D. Monitor the client for pain in the suprapubic region.

Correct Answer is B

Explanation

A. An intravenous pyelogram is a diagnostic test that uses an injection of contrast material to evaluate the kidneys, ureters, and bladder. A bowel cleansing is not necessary.
B. This is important in ensuring that the metal objects do not interfere with the images.
C. Administering oral contrast might be used in other imaging procedures, but for an IVP, the contrast is typically injected, not given orally.
D. Monitoring for pain in the suprapubic region could be an important assessment after the procedure, but it's not a preparatory action.

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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

Naxlex Comprehensive Predictor Exams

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Correct Answer is A

Explanation

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Correct Answer is B

Explanation

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