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 D
Explanation
A. A chest tube to water seal is used to remove air or fluid from the pleural space. This does not directly impact the client's potassium levels.
B. A tracheostomy tube attached to humidified oxygen delivers oxygen directly to the client's airway and does not have a direct effect on potassium levels.
C. An indwelling urinary catheter to gravity drainage does not typically cause significant potassium loss. Urinary catheters primarily collect urine, which contains waste products, rather than electrolytes like potassium.
D. A client with an NG tube to suction may experience loss of gastric contents, which can lead to the loss of electrolytes, including potassium. This places the client at risk for hypokalemia.
Correct Answer is D
Explanation
A. Independently disposing of the remaining medication may not be in compliance with facility policies and could potentially interfere with an investigation into how the medication was left unattended.
B. Returning the medication to the unit's stock for future use is not appropriate, as the vial is already open and its integrity may be compromised.
C. Administering the medication to other clients is absolutely not an option. This could lead to serious harm or even fatal consequences for the other clients involved.
D. When a nurse discovers an open vial of medication left unattended, it is a serious safety concern. The nurse should report the discrepancy immediately to the appropriate personnel or supervisor. This ensures that the situation is addressed promptly and that necessary actions are taken to prevent potential harm to clients.
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