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.

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

Allow the client to walk unassisted near the nursing station

Answer and Explanation

The Correct Answer is B

A. Silence the bed alarm when visitors are at the client's bedside. Bed alarms are a critical safety device for clients on fall precautions and should never be silenced when the client is in bed, regardless of visitors. Alarms alert staff if the client attempts to get up unsafely.
B. Establish an elimination schedule for the client. A regular toileting schedule helps reduce the risk of falls by preventing unassisted attempts to get out of bed to use the bathroom. This proactive approach supports both safety and comfort.
C. Raise all four bed rails on the client's bed. Raising all four rails is considered a form of restraint and can actually increase the risk of injury if the client attempts to climb over them. Two rails up is generally acceptable for support and safety.
D. Allow the client to walk unassisted near the nursing station. Clients on fall precautions should always be supervised or assisted during ambulation to prevent accidents, even when close to staff. Being near the nursing station does not eliminate the risk.

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Correct Answer is B

Explanation

A. Aspirin 1 tablet daily. This prescription is incomplete because it does not specify the dose in milligrams. Aspirin comes in multiple strengths, and clarity is essential to ensure safe administration.
B. Furosemide 20 mg BID. This prescription is complete because it includes the medication name, dosage (20 mg), and frequency (twice daily). It provides all necessary components for safe administration.
C. Nitroglycerin transdermal patch. This order lacks critical details such as the dosage, frequency, and duration of use. Without this information, the prescription is incomplete and cannot be safely implemented.
D. Metoprolol 5 mg now. Although it includes the medication, dosage, and timing, it does not specify the route (e.g., oral, IV), which is necessary for the prescription to be considered complete.

A. "A caesarean birth is the only way to prevent transmission." B. "If you notice genital tingling be sure to notify your provider." C. "Hydrotherapy during labor can help reduce transmission." D. "The provider will perform weekly visual inspections for lesions."

Correct Answer is B

Explanation

A. "A cesarean birth is the only way to prevent transmission." Cesarean delivery is considered if active lesions or prodromal symptoms are present at the time of labor. However, it is not automatically required for all clients with a history of herpes.
B. "If you notice genital tingling be sure to notify your provider." Genital tingling or burning can be a prodromal sign of an impending herpes outbreak. Early reporting allows for appropriate evaluation and potential antiviral treatment to reduce the risk of transmission to the newborn.
C. "Hydrotherapy during labor can help reduce transmission." Hydrotherapy has no effect on herpes virus transmission and is not used for this purpose. Preventing neonatal herpes depends on careful monitoring and antiviral management.
D. "The provider will perform weekly visual inspections for lesions." Routine weekly inspections are not standard unless symptoms suggest an outbreak. Clients are generally monitored and evaluated for lesions closer to labor or if symptoms arise.

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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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