A nurse is caring for a client who is on fall precautions. Which of the following actions should the nurse take?

Silence the bed alarm when visitors are at the client's bedside.

Establish an elimination schedule for the client.

Allow the client to walk unassisted near the nursing station.

Raise all four bed rails on the client's bed.

Answer and Explanation

The Correct Answer is B

A. Silence the bed alarm when visitors are at the client's bedside: Silencing the bed alarm compromises safety by preventing timely notification if the client attempts to get out of bed unassisted. Bed alarms should remain active at all times for clients on fall precautions.

B. Establish an elimination schedule for the client: Scheduling regular toileting reduces the risk of falls by minimizing unassisted trips to the bathroom, which are a common cause of falls, especially in clients with mobility or cognitive impairments. This is an effective and preventive intervention.

C. Allow the client to walk unassisted near the nursing station: Clients on fall precautions should not ambulate without assistance or appropriate safety measures, even near the nursing station, as unassisted walking increases the risk of falls.

D. Raise all four bed rails on the client's bed: Raising all four bed rails can increase the risk of injury if the client attempts to climb over them and is generally considered a restraint, which requires careful assessment and provider authorization.

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Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"B"}

Explanation

Rationale for correct choices

• Spontaneous abortion: The client is at 10 weeks gestation with vaginal bleeding, abdominal cramping, and an open cervix, which are classic findings associated with spontaneous abortion. The presence of cervical dilation indicates that pregnancy loss is actively occurring or imminent. These findings distinguish spontaneous abortion from other early pregnancy complications.

• Cervical dilation: Cervical dilation during early pregnancy is a key indicator of pregnancy loss. In spontaneous abortion, the cervix opens as products of conception begin to pass. This finding provides objective evidence that the pregnancy is not being maintained.

Rationale for incorrect choices

• Molar pregnancy: Molar pregnancy is associated with excessively high hCG levels, uterine enlargement greater than gestational age, and symptoms such as severe nausea or hyperemesis. The client’s hCG level is appropriate for gestational age and does not suggest trophoblastic overgrowth. Cervical dilation is not a defining feature of molar pregnancy.

• Ectopic pregnancy: Ectopic pregnancy typically presents with unilateral pelvic pain, possible shoulder pain, and often no cervical dilation. Vaginal bleeding may occur, but the cervix usually remains closed. Additionally, ectopic pregnancies often have lower-than-expected hCG levels.

• Lower abdominal cramping: Abdominal cramping is a common symptom in many early pregnancy complications and is not specific to spontaneous abortion. While it supports uterine activity, it does not independently confirm pregnancy loss. Cervical dilation provides stronger diagnostic evidence. Cramping alone is insufficient as the primary indicator.

• hCG levels: The client’s hCG level is within the expected range for 10 weeks gestation. Abnormally high levels would suggest molar pregnancy, while low or slowly rising levels might suggest ectopic pregnancy or nonviable gestation. In this case, hCG does not explain the acute findings.

A. Fold the top of the stocking over neatly. B. Massage the client's legs once every 8 hr while the stockings are in place. C. Determine if the stockings are binding. D. Apply the stockings after the client is in a chair.

Correct Answer is C

Explanation

A. Fold the top of the stocking over neatly: Folding the top of antiembolic stockings can create a tourniquet effect, restricting venous return and increasing the risk of skin injury or deep vein thrombosis. Stockings should lie flat without folds to maintain proper circulation.

B. Massage the client's legs once every 8 hr while the stockings are in place: Massaging the legs while antiembolic stockings are on is contraindicated because it can dislodge a thrombus if present, potentially causing a pulmonary embolism. Leg massage should be avoided in clients at risk for thromboembolic events.

C. Determine if the stockings are binding: Assessing whether the stockings are binding or causing constriction is essential. Improperly fitted stockings can impair circulation, lead to skin breakdown, and reduce the prophylactic effect against venous thromboembolism.

D. Apply the stockings after the client is in a chair: Antiembolic stockings should be applied while the client is supine with legs elevated to prevent edema and ensure even pressure distribution. Applying them while seated can reduce effectiveness and increase the risk of skin injury.

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A nurse is caring for a client who is on fall precautions. Which of the following actions should the nurse take?

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Naxlex Comprehensive Predictor Exams

A nurse is caring for a client at the clinic. Complete the following sentence by using the lists of options. The client is at risk for _____ as evidenced by _____ .

Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"B"}

Explanation

A nurse is caring for a client who is wearing antiembolic stockings. Which of the following interventions should the nurse include in the plan of care?

Correct Answer is C

Explanation

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