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 C

Explanation

A. Holding the client's evening dose of digoxin is not the priority at this time. The client's symptoms of confusion and drowsiness require immediate attention to determine the cause.
B. Increasing the client's fluid intake may be important for various reasons, but it is not the most urgent action in this situation. The client's altered mental status and vital signs need to be assessed first.
C. Completing a neurological check is the most appropriate action in this situation. The sudden onset of confusion and drowsiness may indicate a neurological issue that needs to be assessed promptly. This includes assessing the client's level of consciousness, pupillary response, motor function, and other neurological signs.
D. Administering the prescribed PRN antihypertensive medication is not indicated based on the client's current presentation. The client's symptoms are more suggestive of a neurological issue rather than hypertension. It's important to address the altered mental status first.

A. RBC count B. WBC count C. Potassium D. BUN

Correct Answer is B

Explanation

A. An elevation in the red blood cell (RBC) count is not a specific indication of infection. It primarily reflects oxygen-carrying capacity.
B. An elevation in the white blood cell (WBC) count is an indication of infection. When the body is fighting an infection, the number of white blood cells increases as part of the immune response.
C. Potassium is an electrolyte and is not a specific marker for infection. Abnormal potassium levels may indicate a variety of conditions, but they do not directly indicate infection.
D. Blood urea nitrogen (BUN) is a marker of kidney function and is not a specific indicator of infection. Elevated BUN levels can be seen in various kidney and non-kidney-related conditions.

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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.)

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Naxlex Comprehensive Predictor Exams

A nurse on a medical unit is caring for a client who suddenly becomes confused and drowsy. Additional data includes pulse 100/min, respiratory rate 24/min, BP 132/76 mm Hg, and temperature 36.8° C (98.2° F). Which of the following actions should the nurse perform?

Correct Answer is C

Explanation

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Correct Answer is B

Explanation

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