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. Weighing once weekly might not be frequent enough for monitoring changes related to heart failure or medication effects.
B. The timing of hydrochlorothiazide administration isn't critical to safety considerations; it's typically taken in the morning due to its diuretic effect.
C. Leaving a light on in the bathroom at night can help prevent falls, a common concern in older adults, especially those with heart failure.
D. Taking a hot bath before bed might not contribute significantly to safety considerations related to heart failure or medication use.

A. Hold bottles of sterile solution with the label in the palm of the hand. B. Pour liquids into containers outside the sterile field. C. Place the sterile field at the level of the nurse's hips. D. Open the outermost flap of the sterile kit toward the body.

Correct Answer is A

Explanation

A. Holding bottles of sterile solution with the label in the palm of the hand can risk contamination as it involves touching the label. B. Pouring liquids into containers outside the sterile field helps prevent contamination of the field. C. Placing the sterile field at the level of the nurse's hips might not be optimal; it's typically positioned above waist level to maintain sterility. D. Opening the outermost flap of the sterile kit toward the body minimizes the risk of the flap touching non-sterile surfaces during opening.

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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

A nurse is providing discharge teaching about safety considerations to an older adult client who lives at home. The client has heart failure and a new prescription for hydrochlorothiazide. Which of the following statements by the client indicates an understanding of the teaching?

Correct Answer is C

Explanation

A nurse is preparing to set up a sterile field. Which of the following actions should the nurse take?

Correct Answer is A

Explanation

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