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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Free Nursing Study Resources

Correct Answer is A

Explanation

A. When administering a cleansing enema, it is important to hold the container of solution about 30 cm (12 in) above the anus. This provides enough gravitational force for the solution to flow gently into the rectum.
B. This action involves unnecessary movement of the container and is not a standard technique for administering a cleansing enema.
C. Holding the container level with the client's upper hip does not provide sufficient height for the gravitational force needed to administer the enema effectively.
D. Keeping the container at a level to maintain client comfort is not specific guidance for administering a cleansing enema. The height of the container above the anus is a critical factor in ensuring the enema flows properly.

A. Request a prescription for an indwelling urinary catheter. B. Take the client to the bathroom every 2 hr. C. Remind the client to tell the nurse when he has to urinate. D. Use adult diapers to prevent frequent clothing changes. E. Use adult diapers to prevent frequent clothing changes.

Correct Answer is B

Explanation

A. Using an indwelling urinary catheter should be avoided unless absolutely necessary due to the associated risks of infection and other complications. It's not the first-line intervention for managing urinary incontinence.
B. Frequent toileting, also known as scheduled toileting or prompted voiding, is an effective intervention for managing urinary incontinence in older adults with dementia. It helps prevent accidents by ensuring the client has regular opportunities to use the
bathroom.
C. Reminding the client to tell the nurse when they need to urinate can be helpful, but it may not be sufficient on its own, especially for individuals with dementia who may have difficulty recognizing or communicating their needs.
D. Using adult diapers should be considered a last resort, as it does not address the underlying issue and may not promote the client's independence or dignity.

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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.)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is preparing to administer a cleansing enema to a client. Which of the following actions should the nurse take?

Correct Answer is A

Explanation

Correct Answer is B

Explanation

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