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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Draw up regular insulin prior to NPH insulin. This is the correct technique when mixing short-acting (regular) and intermediate-acting (NPH) insulins in the same syringe. Drawing up regular insulin first prevents contamination of the clear insulin vial with the cloudy NPH, which could alter the action of the regular insulin.
B. Roll the syringe gently to ensure mixture of the insulins. Insulin should be mixed in the vial before drawing it into the syringe—not after. NPH insulin should be gently rolled between the hands to mix it, but the syringe itself should not be rolled after drawing both insulins, as this can introduce bubbles and affect dosing accuracy.
C. Inject into the vastus lateralis. The preferred sites for subcutaneous insulin administration are areas with sufficient subcutaneous tissue, such as the abdomen, upper outer arms, thighs, or buttocks. The vastus lateralis is more commonly used for intramuscular injections, such as vaccines.
D. Use a 15° angle for the injection. A 15° angle is appropriate for intradermal injections, not subcutaneous insulin injections. For insulin, the correct angle is typically 45° or 90°, depending on the client’s body habitus and needle length, to ensure proper subcutaneous delivery.
Correct Answer is B
Explanation
A. Premature atrial complexes. These are early electrical impulses originating in the atria that cause premature heartbeats, but they do not consistently lengthen the P-R interval. The P-R interval usually remains within normal limits unless another condition is present.
B. First-degree atrioventricular (AV) block. A constant P-R interval longer than 0.20 seconds (normal range: 0.12–0.20 seconds) is characteristic of a first-degree AV block. A P-R interval of 0.35 seconds indicates a prolonged conduction delay through the AV node, consistent with this dysrhythmia.
C. Complete heart block. In complete (third-degree) heart block, there is no consistent relationship between P waves and QRS complexes, and the P-R interval is not constant. This is not consistent with a stable, prolonged P-R interval.
D. Atrial fibrillation. Atrial fibrillation is marked by irregularly irregular rhythm and absent, unidentifiable P waves, not a consistent P-R interval. The atria are quivering, not contracting in a coordinated way.
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