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 C
Explanation
A. "You should make sure your partner takes the prescribed medication." While medication adherence is important, this response shifts the focus to advice-giving rather than exploring the partner’s emotions or current experience, which limits therapeutic communication.
B. "You did the right thing by bringing your partner in for treatment." Although supportive, this statement closes off the conversation and doesn’t invite the partner to share more about their feelings or the situation at home.
C. "Can you talk about what was happening with your partner at home?" This open-ended, therapeutic response encourages the partner to express their thoughts and emotions, facilitating a better understanding of the client’s condition and the impact it has had on the family.
D. "Why do you think your partner's symptoms are progressing so quickly?" Asking “why” can feel accusatory or put the partner on the defensive. It may also imply blame, which is not helpful in building trust or gathering therapeutic insight.
Correct Answer is D
Explanation
A. Use tubing that does not have a filter in the drip chamber. Blood transfusion tubing must have a filter to trap clots, cellular debris, and other particulates, ensuring the safe administration of blood products.
B. Use an IV catheter that is at least 24-gauge. A larger bore catheter (18- to 20-gauge) is preferred for blood transfusions to reduce the risk of hemolysis and allow adequate flow. A 24-gauge is too small for standard transfusion protocols.
C. Attach a single line administration set. A Y-type tubing set is typically used, allowing for connection to both the blood product and normal saline. This setup enables flushing before and after the transfusion and provides a safe delivery system.
D. Prime the tubing with 0.9% sodium chloride. Only 0.9% sodium chloride (normal saline) should be used to prime the tubing, as it is compatible with blood products and prevents hemolysis or clot formation. Dextrose or other solutions can cause serious reactions.
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