A nurse is caring for a client who is at risk for falls. Which of the following actions should the nurse take? (Select all that apply.)
Keep the client's bed in the lowest position.
Assess the client every 4 hr.
Keep the client's room dark at night.
Teach the client to use the call light.
Place a fall-risk identification band on the client's wrist.
Correct Answer : A,D,E
A. Keeping the client's bed in the lowest position helps minimize the potential fall distance if the client attempts to get out of bed.
B. Assessing the client every 4 hours is a good practice for general monitoring but may not be specific to fall prevention. More frequent assessments may be necessary for a client at high risk for falls.
C. Keeping the client's room dark at night can actually increase the risk of falls. It's important to ensure there is adequate lighting to help the client navigate safely.
D. Teaching the client to use the call light allows them to request assistance when needed, reducing the likelihood of attempting to move or get out of bed independently.
E. Placing a fall-risk identification band on the client's wrist helps alert all healthcare providers that the client is at risk for falls. This information is crucial for ensuring appropriate precautions are taken.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Washing the tablet off with alcohol and placing it in a clean medication may not effectively remove all potential contaminants and could alter the medication. It's safer to discard it.
B. Using the tablet's packaging to pick it up may not guarantee that the tablet is still clean or free from contamination.
C. Discarding the tablet and obtaining another dose of medication is the safest and most appropriate action. This ensures that the client receives a clean and uncontaminated dose of medication.
D. Placing the tablet directly into a medication cup without any further cleaning is not recommended, as it could introduce potential contaminants into the client's medication.
Correct Answer is ["A","B","D","E"]
Explanation
A. Wearing a mask helps protect against the transmission of airborne particles, which is important for preventing the spread of tuberculosis.
B. Wearing a gown can provide an additional barrier to prevent the transmission of infectious material.
C. Disposing sharps here is not directly related to tuberculosis precautions. This statement is more relevant for a sharps disposal container.
D. Wearing gloves is important to prevent direct contact with potentially contaminated surfaces.
E. Hand hygiene is crucial for infection control and should be emphasized for anyone entering or exiting the room of a client in isolation.
F. "Radiation inside" is not applicable to the isolation precautions for tuberculosis. This statement is unrelated to tuberculosis precautions and may cause confusion.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.