A nurse is assisting with the development of a plan of care for an older adult who is at risk for falls. Which of the following actions should the nurse contribute to the plan? (Select all that apply)

Keep the bed at a comfortable working height.

Administer a sedative at bedtime.

Keep a night light on in the client's room and bathroom.

Place the bedside table within the client's reach.

Lock the wheels on beds and wheelchairs during transfers.

Answer and Explanation

Correct Answer : C,D,E

Keeping a night light on in the client's room and bathroom can help reduce the risk of falls by improving visibility and orientation at night. Placing the bedside table within the client's reach can help reduce the risk of falls by making it easier for the client to access necessary items without having to get up and move around. Locking the wheels on beds and wheelchairs during transfers can help reduce the risk of falls by providing stability and preventing unwanted movement.

a. Keeping the bed at a comfortable working height is important for the nurse's comfort and safety while providing care, but it does not directly reduce the risk of falls for the client.

b. Administering a sedative at bedtime may help the client sleep, but it can also increase the risk of falls by causing drowsiness and disorientation.

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Correct Answer is B

Explanation

The nurse should place the client's right leg in abduction following a right total hip arthroplasty. Abduction means moving the leg away from the midline of the body. This position helps to prevent hip dislocation by keeping the hip joint in proper alignment.

Internal rotation, adduction, and external rotation are not appropriate positions for the client's right leg following a right total hip arthroplasty. Internal rotation means turning the leg inward towards the midline of the body. Adduction means moving the leg towards the midline of the body. External rotation means turning the leg outward away from the midline of the body. These positions can increase the risk of hip dislocation.

A. Maintain the client on bed rest for 72 hr after surgery. B. Check capillary refill in the aﬀected extremity every 4 hr. C. Restrict oral ﬂuid intake to 1,000 ml per day. D. Remove antiembolic stockings once each day to examine skin integrity.

Correct Answer is B

Explanation

Checking capillary refill in the aﬀected extremity every 4 hr is an important intervention for a nurse to include in the plan of care for an older adult client who is 4 hr postoperative following an open reduction and internal fixation of a fractured femur. This helps to monitor the blood flow to the aﬀected extremity and ensure that it is adequate.

a. Maintaining the client on bed rest for 72 hr after surgery is not necessarily required for a patient who has undergone an open reduction and internal fixation of a fractured femur. The patient's mobility should be determined by their individual needs and the surgeon's instructions.

c. Restricting oral ﬂuid intake to 1,000 ml per day is not necessary for a patient who has undergone an open reduction and internal fixation of a fractured femur. The patient's ﬂuid intake should be determined by their individual needs and any medical conditions they may have.

d. Removing antiembolic stockings once each day to examine skin integrity is not necessarily required for a patient who has undergone an open reduction and internal fixation of a fractured femur. The use of antiembolic stockings and their removal should be determined by the patient's individual needs and the surgeon's instructions.

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A nurse is assisting with the development of a plan of care for an older adult who is at risk for falls. Which of the following actions should the nurse contribute to the plan? (Select all that apply)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who is postoperative following a right total hip arthroplasty. In which of the following positions should the nurse place the client's right leg?

Correct Answer is B

Explanation

A nurse is assisting with the plan of care for an older adult client who is 4 hr postoperative following an open reduction and internal fixation of a fractured femur. Which of the following interventions should the nurse include in the plan of care?

Correct Answer is B

Explanation

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