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.

Keep the client's room temperature at 18° C (64.4" F).

Provide the client with a night light.

Answer and Explanation

The Correct Answer is D

A. Elevate full-length side rails on both sides of the client's bed:

While side rails are used to prevent falls, full-length side rails can pose a risk to the client. They may give a false sense of security, and there's a risk of entrapment or injury if the client tries to climb over them. The use of side rails requires careful assessment and consideration of the individual client's needs.

B. Place the bedside table 0.9 m (3 feet) away from the bed:

Placing the bedside table 0.9 m (3 feet) away from the bed may not directly address the risk of falls. The focus should be on making essential items easily accessible to the client to minimize the need for them to get out of bed, especially during the night. Placing items within the client's reach is a more practical approach.

C. Keep the client's room temperature at 18°C (64.4°F):

While maintaining a comfortable room temperature is important for the client's overall well-being, it is not a direct preventive measure for falls. Falls are more likely to be prevented by addressing environmental factors, ensuring clear pathways, and providing adequate lighting.

D. Provide the client with a night light:

This is the appropriate action. A night light helps improve visibility during nighttime, reducing the risk of falls. It allows the client to see their surroundings better and navigate the room safely if they need to get out of bed.

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Correct Answer is A

Explanation

A. Endotracheal suctioning:

This is the correct answer. If a client requires endotracheal suctioning, it is likely due to respiratory distress or compromised airway clearance. Ensuring a patent airway and maintaining adequate oxygenation is the top priority, making endotracheal suctioning the first procedure to be performed.

B. Urinary catheter care:

Urinary catheter care is important for preventing infections and maintaining urinary function, but it is generally not as urgent as addressing respiratory distress. If the client is experiencing respiratory issues, addressing these concerns should take precedence.

C. Enteral feeding:

While enteral feeding is essential for providing nutrition, it is not typically as urgent as addressing respiratory needs. If a client requires endotracheal suctioning for respiratory support, it should be prioritized over enteral feeding.

D. Wound irrigation:

Wound irrigation is important for wound care, but it is generally not as time-sensitive as addressing respiratory needs. If the client's airway is compromised, it takes precedence over wound irrigation.

A. "You need to understand that you have very little time left." B. "I will contact your provider to discuss your options." C. "Enjoy the time you have and do the things you want to do." D. "Hospice care is the best thing for you at this time."

Correct Answer is B

Explanation

A. "You need to understand that you have very little time left":

This response is blunt and may be emotionally distressing for the client. It is essential to communicate with sensitivity and respect the client's autonomy. This option does not explore the available treatment options, which is important in this situation.

B. "I will contact your provider to discuss your options":

This is the correct answer. It demonstrates the nurse's commitment to the client's wishes by taking proactive steps to explore treatment options. Involving the healthcare provider in the discussion allows for a more informed decision-making process and ensures that the client's preferences are considered in the overall care plan

C. "Enjoy the time you have and do the things you want to do":

This response may come across as dismissive and does not directly address the client's expressed desire for more treatment. It is important to acknowledge the client's wishes and explore available options before discussing end-of-life activities.

D. "Hospice care is the best thing for you at this time":

While hospice care is an important consideration for individuals with terminal illnesses, it may not align with the client's current preference for more treatment. Introducing hospice care at this point without discussing treatment options may be premature.

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