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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Aspirin 1 tablet daily: This prescription is incomplete because it does not specify the dosage strength (e.g., 81 mg or 325 mg). Without the strength, safe administration cannot be ensured.
B. Metoprolol 5 mg IV now: This prescription is complete because it includes the medication name, exact dosage, route of administration, and timing (“now”), providing all necessary information for safe administration.
C. Nitroglycerin transdermal patch: This prescription is incomplete as it does not specify the dosage strength (e.g., 0.1 mg/hr), location of application, or timing, which are necessary for safe and effective use.
D. Furosemide 20 mg BID: This prescription is incomplete because it does not specify the route of administration (oral or IV), which is essential for safe administration and proper monitoring of effects.
Correct Answer is B
Explanation
A. Esophagitis: Esophagitis is not a typical manifestation of systemic lupus erythematosus (SLE). While SLE can affect multiple organ systems, gastrointestinal involvement usually presents as abdominal pain, nausea, or pancreatitis, rather than inflammation of the esophagus.
B. Fever: Fever is a common systemic manifestation during an acute SLE exacerbation due to immune system activation and widespread inflammation. It reflects the inflammatory response and cytokine release associated with disease flare-ups.
C. Diplopia: Diplopia (double vision) is not a common feature of SLE exacerbations. Neurologic involvement in SLE more frequently presents as headache, seizures, cognitive dysfunction, or peripheral neuropathy rather than isolated visual disturbances.
D. Bradykinesia: Bradykinesia, or slowness of movement, is characteristic of Parkinson’s disease and other movement disorders, not SLE. Musculoskeletal manifestations of SLE typically include joint pain, stiffness, and swelling without the motor deficits seen in bradykinesia.
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