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: The presence of an area rug over a tile floor poses a tripping hazard, which is particularly dangerous for individuals with osteoporosis due to the increased risk of fractures from falls. The rug can easily slip or edges can curl, leading to potential accidents. Therefore, it is crucial for the nurse to address this issue to prevent falls.

B: Grab bars in the shower are a safety feature that assists individuals in maintaining balance and preventing slips, which is beneficial for a person with osteoporosis. There is no need for intervention as this is a recommended safety measure.

C: Storing prescriptions in a medication organizer is a good practice as it helps ensure that medications are taken correctly and on time. This is especially important for older adults who may have multiple prescriptions. Thus, no intervention is needed here.

D: Setting the hot water heater to 47° C (117° F) can pose a risk of burns, especially for older adults whose skin may be more sensitive and who may have a delayed reaction to withdraw from hot surfaces. However, this is not directly related to osteoporosis, and while it is a safety concern, it is not as immediately hazardous as a tripping risk.

A. At the end of the shift B. When removing the medication from the medication drawer C. Directly before administering the medication D. When reconciling counts of controlled substances E. When preparing the medication dosage

Correct Answer is ["B","C","E"]

Explanation

A. At the end of the shift is incorrect. Medication verification is done before administration, not at the end of the shift.

B. When removing the medication from the medication drawer is correct. This is the first check to ensure the correct medication is selected.

C. Directly before administering the medication is correct. This is the final check to verify that the correct medication, dose, route, and time match the prescription before giving it to the client.

D. When reconciling counts of controlled substances is incorrect. While controlled substances require counting and verification, this is separate from the three medication checks performed during administration.

E. When preparing the medication dosage is correct. This is the second check, ensuring that the correct medication and dose are prepared accurately before administration.

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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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Naxlex Comprehensive Predictor Exams

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Correct Answer is A

Explanation

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Correct Answer is ["B","C","E"]

Explanation

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