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. Open the outermost flap of the sterile kit toward the body. The outermost flap should always be opened away from the body first to prevent contamination of the sterile field by leaning over it. This helps maintain sterility by minimizing the risk of contact.
B. Place the cap from the solution sterile side up on a clean surface. Placing the cap sterile side up prevents the sterile inner surface from touching the contaminated surface and helps maintain aseptic technique during solution use.
C. Place the sterile dressing within 1.25 cm (0.5 in) of the edge of the sterile field. The outer 2.5 cm (1 inch) border of a sterile field is considered contaminated. Placing items too close to the edge increases the risk of contamination and compromises the field's sterility.
D. Set up the sterile field 5 cm (2 in) below waist level. Any sterile item held or placed below waist level is considered contaminated. The sterile field must always be maintained above waist level to preserve asepsis.

A. "Morphine 3.0 mg sub q every 4 hr PRN for pain." B. "Morphine 3 mg subcutaneous every 4 hr PRN for pain." C. "Morphine 3 mg SC q 4 hr PRN for pain." D. "Morphine 3 mg SQ every 4 hr PRN for pain."

Correct Answer is B

Explanation

A. "Morphine 3.0 mg sub q every 4 hr PRN for pain." Including a trailing zero (3.0 mg) is considered unsafe and is discouraged in medication documentation. It increases the risk of a tenfold overdose if the decimal is missed.
B. "Morphine 3 mg subcutaneous every 4 hr PRN for pain." This entry uses the correct dosage format without a trailing zero, the full term "subcutaneous" instead of abbreviations, and proper medical terminology. It adheres to safe documentation practices as per The Joint Commission guidelines.
C. "Morphine 3 mg SC q 4 hr PRN for pain." The abbreviation “SC” is considered unsafe and prone to misinterpretation. Also, "q" for "every" is discouraged in clinical documentation due to potential misreading and error.
D. "Morphine 3 mg SQ every 4 hr PRN for pain." The abbreviation “SQ” can be misinterpreted or mistaken for “5 every” or other terms. Safe practice requires spelling out “subcutaneous” to prevent errors in medication administration.

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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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