A nurse is caring for a client who has dementia and is at risk for falls. Which of the following preventive measures should the nurse take?

Place the client’s bed in the low position.

Encourage the client to wear socks when ambulating.

Position the client’s bedside table at the foot of the bed.

Raise four side rails on the client’s bed.

Answer and Explanation

The Correct Answer is A

This is because lowering the bed reduces the risk of injury if the client falls out of the bed. It also makes it easier for the client to get in and out of the bed safely.

Choice B is wrong because wearing socks when ambulating can increase the risk of slipping and falling. The client should wear shoes or slippers with non-skid soles.

Choice C is wrong because positioning the client’s bedside table at the foot of the bed can create an obstacle for the client to walk around. The bedside table should be placed near the head of the bed and within reach of the client.

Choice D is wrong because raising four side rails on the client’s bed can be considered a form of restraint and can increase the risk of injury if the client tries to climb over them. The use of restraints should be avoided for clients with dementia, as they can cause agitation, confusion, and distress. Instead, other measures such as bed alarms, motion sensors, or frequent monitoring should be used to prevent falls.

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Correct Answer is D

Explanation

Insulin lispro was administered to a client immediately before bed. This is a situation that requires the completion of an incident report because insulin lispro is a rapid-acting insulin that should be given within 15 minutes before or after a meal. Giving it immediately before bed can cause hypoglycemia (low blood sugar) during the night, which can be dangerous for the client.

Choice A is wrong because nitroglycerin transdermal is a medication used to prevent angina (chest pain) and can be applied to a client’s chest as prescribed.

Choice B is wrong because cefotaxime is an antibiotic that can be administered to a client after obtaining blood cultures to treat an infection.

Choice C is wrong because digoxin is a medication used to treat heart failure and atrial fibrillation and can be administered to a client who has a heart rate of 64/min, which is within the normal range of 60 to 100 beats per minute.

A. A client who is 2 days postpartum and whose fundus is 2 to 4 cm below the umbilicus. B. A client who is 3 days postpartum and has not had a bowel movement since prior to admission. C. A client who is 4 days postpartum and has lochia serosa. D. A client who is 1 day postpartum and has not voided in 8 hr.

Correct Answer is D

Explanation

A client who is 1 day postpartum and has not voided in 8 hr. This client is at risk of urinary retention, bladder distension, and infection due to the effects of epidural anesthesia, perineal trauma, and fluid shifts after delivery. The nurse should assess the client’s bladder and catheterize if necessary.

Choice A is wrong because a client who is 2 days postpartum and whose fundus is 2 to 4 cm below the umbilicus is showing a normal finding.

The fundus should descend about 1 to 2 cm per day after delivery and be nonpalpable by day 10.

Choice B is wrong because a client who is 3 days postpartum and has not had a bowel movement since prior to admission is not uncommon.

Constipation is a common problem after delivery due to decreased peristalsis, dehydration, and fear of pain.

The nurse should encourage fluid intake, fiber intake, and early ambulation to promote bowel function.

Choice C is wrong because a client who is 4 days postpartum and has lochia serosa is also showing a normal finding.

Lochia serosa is the pinkish-brown discharge that occurs from day 4 to 10 after delivery.

It consists of old blood, serum, leukocytes, and tissue debris.

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A nurse is caring for a client who has dementia and is at risk for falls. Which of the following preventive measures should the nurse take?

Nursing Test Bank

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