A nurse is caring for a client who has a history of falling at their assisted living facility. The client is oriented
to person, place, and time and can follow directions. Which of the following actions should the nurse take to decrease the risk of another fall?

Apply restraints to the hands or wrists to keep the patient in bed.

Place a belt restraint on the client when they are sitting in a chair.

Keep the bed in lowest position with all four side rails up.

Educate the patient on using the call light and make sure the call light is within reach.

Answer and Explanation

The Correct Answer is D

A. Apply restraints to the hands or wrists to keep the patient in bed: Restraints should only be used when absolutely necessary and as a last resort, and the client in this scenario is oriented and can follow instructions. Restraints can also increase the risk of injury, agitation, and further falls.

B. Place a belt restraint on the client when they are sitting in a chair: Belt restraints restrict movement and should only be used when other measures are insufficient to protect the client. Since the client is oriented and can follow directions, this intervention is not warranted and could cause harm.

C. Keep the bed in the lowest position with all four side rails up:
Incorrect. Raising all four side rails is considered a form of restraint and can increase the risk of injury. Clients may attempt to climb over the side rails, leading to falls. Keeping the bed in a low position is appropriate, but using all four side rails is not.

D. Educate the patient on using the call light and make sure the call light is within reach. This is the most appropriate action as the client is oriented and can follow directions. Educating the patient on how to use the call light and ensuring it is easily accessible encourages them to ask for assistance when needed, reducing the risk of falls.

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Correct Answer is C

Explanation

The correct answer is choice C. Signs of a wound infection include redness, warmth, and tenderness around the wound, as well as fever, chills, and malaise. The wound base may appear yellow, indicating the presence of pus, and may have a foul odor. Serous drainage is typically clear and does not indicate infection, while serosanguineous drainage may indicate a mild infection or normal healing process. An oral temperature of 101.5°F is elevated and may indicate an infection.

A. Sit out of bed in the chair. B. Verbalize feelings about surgery at some point. C. Eat low sodium food. D. Identify the five major drug side effects before discharge tomorrow.

Correct Answer is D

Explanation

The correct answer is choice D. Identify the five major drug side effects before discharge tomorrow. A measurable client goal should be specific, observable, and

measurable. It should describe a behavior or outcome that the client can achieve. Identifying the five major drug side effects is specific and measurable. Sitting out of bed in a chair is too general, while verbalizing feelings about surgery at some point is not observable and not time-bound. Eating low sodium food is specific but not measurable.

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A nurse is caring for a client who has a history of falling at their assisted living facility. The client is oriented to person, place, and time and can follow directions. Which of the following actions should the nurse take to decrease the risk of another fall?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client with a wound on the lower extremity. What findings would the nurse observe that would indicate a wound infection?

Correct Answer is C

Explanation

Which of the following is the best example of a measurable client goal? The client will:

Correct Answer is D

Explanation

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A nurse is caring for a client who has a history of falling at their assisted living facility. The client is oriented
to person, place, and time and can follow directions. Which of the following actions should the nurse take to decrease the risk of another fall?