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.

Answer and Explanation

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.

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Correct Answer is A

Explanation

A. Determining the location of the pain is the first step in assessing and managing a client's pain. It helps the nurse gather important information about the nature and potential causes of the pain.
B. Administering the medication may be necessary, but it should come after the nurse has assessed the location and characteristics of the pain to ensure the correct medication and dosage are given.
C. Repositioning the client can be important for comfort and pain relief, but it should come after the nurse has assessed the location of the pain to determine the best position for the client.
D. Reviewing the effects of the pain medication is important, but it should come after the nurse has administered the medication. It is essential to first address the client's request for pain relief by assessing the pain location and administering the appropriate
medication.

A. Elevate the head of the bed no more than 45°. B. Use a transfer device to lift the client up in bed. C. Massage the skin over the client's bony prominences. D. Apply cornstarch to keep sensitive skin areas dry.

Correct Answer is A

Explanation

A. Elevating the head of the bed helps to reduce pressure on bony prominences, especially the sacral area, and can help prevent pressure ulcers. However, the head of the bed should not be elevated more than 30 degrees to 45 degrees to maintain skin integrity.
B. Using a transfer device is important for moving the client safely, but it is not specifically related to maintaining skin integrity.
C. Massaging the skin over bony prominences is not recommended as it can increase friction and shear, which can contribute to pressure ulcer development.
D. Applying cornstarch is not typically recommended for pressure ulcer prevention. It can create a moist environment that may contribute to skin breakdown, especially in areas where moisture can become trapped.

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