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 A
Explanation
A. Perform bimanual fundal massage: Excessive vaginal bleeding postpartum often indicates uterine atony. Performing a bimanual fundal massage helps stimulate uterine contraction, which can reduce hemorrhage. This is a primary and immediate intervention in postpartum bleeding management.
B. Weigh perineal pads: Weighing pads helps quantify blood loss but does not actively stop hemorrhage. While important for assessment and documentation, it is not the first action when the client is actively bleeding.
C. Initiate oxygen at 2 L/min via nasal cannula: Administering oxygen may support tissue oxygenation but does not address the underlying cause of postpartum hemorrhage. Oxygen is supportive care and should not replace interventions to control bleeding.
D. Administer terbutaline: Terbutaline is a uterine relaxant used to treat preterm labor, which would worsen postpartum bleeding by inhibiting uterine contraction. It is contraindicated in cases of active postpartum hemorrhage.
Correct Answer is A
Explanation
A. Inspect the skin under the boot every 8 hr: Frequent skin assessment is critical for clients in Buck's traction because the traction boot or straps can cause pressure injuries, skin breakdown, or irritation. Checking the skin every 8 hours allows early detection of redness, sores, or areas of compromised circulation and prevents complications associated with prolonged immobility and pressure.
B. Assess the client's peripheral circulation every 12 hr: Peripheral circulation should be assessed more frequently than every 12 hours, typically every 1–2 hours initially, to detect early signs of neurovascular compromise such as cyanosis, pallor, coolness, or numbness. Waiting 12 hours could delay identification of circulation issues that may lead to tissue damage or compartment syndrome.
C. Ensure the weights are resting on the floor: Traction weights must hang freely to maintain proper alignment and effective traction. Allowing the weights to rest on the floor disrupts the pulling force, reducing traction effectiveness, increasing pain, and potentially worsening fracture displacement.
D. Remove the traction to allow the client to use the bathroom: Buck's traction should not be removed for routine activities such as toileting because interrupting traction can cause misalignment, increased pain, and delayed healing. Alternative methods, such as a bedside commode or urinal, should be used while maintaining traction integrity.
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