A nurse is caring for a client who is at risk for a fall because of orthostatic hypotension. Which of the following actions should the nurse take?
Keep all four of the side rails raised on the client's bed.
Check the client every 4 hr to evaluate their need to use the restroom.
Instruct the client to stand in place when beginning ambulation.
Maintain the client's bed at the nurse's waist level.
The Correct Answer is C
A. Keep all four of the side rails raised on the client's bed: Raising all four side rails can increase the risk of injury if the client attempts to climb over them. Full side rails are not a recommended fall-prevention strategy for clients with orthostatic hypotension.
B. Check the client every 4 hr to evaluate their need to use the restroom: Checking every 4 hours may not be frequent enough to prevent falls related to sudden episodes of dizziness or urgency. More proactive measures, such as assisting with ambulation, are safer for clients at risk.
C. Instruct the client to stand in place when beginning ambulation: Having the client stand in place for a few moments allows blood pressure to stabilize before walking, reducing the risk of dizziness and falls caused by orthostatic hypotension. This is a key intervention for fall prevention in at-risk clients.
D. Maintain the client's bed at the nurse's waist level: The bed height should be adjusted to facilitate safe transfers, typically at the level that allows feet to touch the floor and promotes stability. Keeping the bed at the nurse's waist level does not specifically prevent falls due to orthostatic hypotension.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["B","C","D"]
Explanation
Rationale:
A. Encourage the client to drink 3000 mL of fluid daily: This is contraindicated because the client has heart failure with signs of fluid volume excess (crackles and 3+ pitting edema). Increasing fluid intake could worsen fluid overload.
B. Review the need for the indwelling urinary catheter daily: Daily assessment of catheter necessity allows for timely removal when it is no longer needed, which significantly decreases the risk of catheter-associated urinary tract infections (CAUTIs).
C. Empty the drainage bag when it is half-full: Keeping the drainage bag from becoming overfilled prevents urine backflow into the bladder, which can introduce bacteria and increase infection risk. Regular emptying is a key preventive measure.
D. Use soap and water to provide perineal care: Proper perineal hygiene with mild soap and water helps remove bacteria and maintain skin integrity, reducing the risk of urinary tract infection, especially in incontinent clients.
E. Place the drainage bag on the bed when transporting the client: The drainage bag should always remain below the level of the bladder and off the bed to prevent backflow of urine, which can introduce bacteria and increase infection risk.
F. Change the indwelling urinary catheter tubing every 3 days: Routine scheduled tubing changes are not recommended, as unnecessary manipulation of the system can increase infection risk. Tubing should only be changed when clinically indicated (e.g., contamination, obstruction).
Correct Answer is A
Explanation
A. Recurrent UTI: Frequent urinary tract infections can be a sign of gestational diabetes mellitus (GDM) because hyperglycemia creates an environment conducive to bacterial growth. Recurrent infections may indicate impaired glucose regulation and warrant further screening for GDM.
B. Family history of type 2 diabetes mellitus: While a family history increases the client’s risk for developing GDM, it is not a direct indicator that the client currently has gestational diabetes. It is considered a risk factor rather than a presenting finding.
C. Heart rate is consistently between 55/min and 58/min: A slightly lower maternal heart rate is not indicative of gestational diabetes. Maternal bradycardia in this range is usually not related to glucose metabolism and may be influenced by other factors such as fitness level or medication use.
D. Reports decrease in urination frequency: Gestational diabetes typically causes polyuria rather than decreased urination. Reduced urination is not a characteristic finding associated with GDM and may suggest other renal or hydration issues instead.
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