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 A
Explanation
A. Eat a light snack before bedtime: Consuming a small, easily digestible snack, such as a piece of fruit or a glass of milk, can help prevent hunger-related awakenings and promote relaxation, supporting better sleep in older adults.
B. Take a 1-hr nap during the day: Long daytime naps can disrupt the sleep-wake cycle and contribute to difficulty falling asleep at night. Short naps (20–30 minutes) earlier in the day are preferable for older adults.
C. Stay in bed at least 1 hr if unable to fall asleep: Remaining in bed when unable to sleep can reinforce negative associations between the bed and wakefulness, potentially worsening insomnia. Clients should get out of bed and engage in a quiet activity until sleepy.
D. Perform exercises prior to bedtime: Vigorous exercise close to bedtime can increase arousal, heart rate, and body temperature, making it harder to fall asleep. Exercise is best scheduled earlier in the day to promote nighttime sleep.
Correct Answer is ["B","D","E","F"]
Explanation
Rationale for correct choices
• Deep tendon reflexes (DTR) 2+ bilaterally: At 1400, the client’s DTRs were severely diminished at 1+, a hallmark sign of magnesium toxicity. The return of DTRs to 2+ demonstrates recovery of neuromuscular function, indicating that magnesium levels are moving back into the safe therapeutic range and the risk of severe complications like paralysis is decreasing.
• Urine output 40 mL in the last hour: Adequate urine output shows the kidneys are effectively excreting magnesium. Magnesium toxicity is more likely when renal function is impaired. Improvement in urine output indicates the body is eliminating excess magnesium, supporting recovery and reducing ongoing toxicity risk.
• Respiratory rate 18/min with oxygen saturation 95% on 2 L nasal cannula: Previously, the client had a severely depressed respiratory rate of 8/min and oxygen saturation of 91%, indicating significant magnesium-induced respiratory depression. The increase to 18 breaths/min with improved oxygenation reflects restoration of respiratory function, which is an indicator of improvement from magnesium toxicity.
Rationale for findings not indicating improvement
• Temperature 38.3° C (101° F): Fever does not reflect magnesium toxicity or its resolution. This is a new finding of fever, which may indicate the development of an infection (such as chorioamnionitis or a UTI from the catheter) or a reaction to medications.
• Blood pressure 146/96 mm Hg: While slightly lower than the peak of 156/96, the diastolic pressure (96) remains high, indicating the underlying preeclampsia is still active and unresolved.
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