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 ["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.

A. A nurse begins a blood transfusion without obtaining consent from a client. B. An assistive personnel prevents a client from leaving the facility. C. A nurse administers a medication without first identifying the client. D. An assistive personnel discusses client care in the facility cafeteria with visitors present.

Correct Answer is C

Explanation

A. Starting a blood transfusion without obtaining consent is a violation but may fall more under the category of battery than negligence.
B. Preventing a client from leaving the facility might relate more to issues of false imprisonment or breach of autonomy rather than negligence.
C. Administering medication without properly identifying the client can be considered negligence as it breaches the standard duty of care.
D. Discussing client care in a public area with visitors present might breach confidentiality but might not be categorized as negligence unless sensitive or protected information was disclosed.

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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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Explanation

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