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 oneself once weekly may not be frequent enough to monitor changes related to heart failure or medication effects.
B. Taking hydrochlorothiazide in the evening is not usually a crucial safety consideration; it is typically taken in the morning due to its diuretic effects.
C. Leaving a light on in the bathroom at night can prevent falls, which are a significant concern in older adults with heart failure.
D. Taking a hot bath before bedtime might not be a safety consideration related to heart failure or medication use and could potentially cause issues with temperature regulation or dehydration.

A. Side-lying with the right side of the chest elevated B. Right lateral in Trendelenburg position C. Prone with pillows under the lower extremities D. Supine in low-Fowler's position

Correct Answer is B

Explanation

Rationale for A: Side-lying with the right side of the chest elevated does not provide the necessary gravitational effect to drain the left lower lobe. The Trendelenburg position is more effective for lower lobe drainage.

Rationale for B: Right lateral in Trendelenburg position is the appropriate position for postural drainage of the left lower lobe. The combination of gravity and positioning helps drain secretions from the lower lobe effectively.

Rationale for C: Prone with pillows under the lower extremities does not facilitate proper drainage of the left lower lobe. This position might be more useful for posterior lobe drainage, not the lower lobes.

Rationale for D: Supine in low-Fowler's position is not ideal for draining secretions from the lower lobes of the lungs. Postural drainage requires specific positions that use gravity to promote secretion clearance from the affected lobe.

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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 C

Explanation

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Correct Answer is B

Explanation

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