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.
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Related Questions
Correct Answer is ["E","F","G"]
Explanation
A. Request a prescription for terbutaline from the provider. Terbutaline is a tocolytic used to stop preterm labor, not indicated in this postpartum scenario. The client is already on uterotonic therapy (methylergonovine), which is appropriate for postpartum uterine atony.
B. Obtain a culture specimen of the lochia from the client's perineal pad using a sterile swab is inappropriate because the pad is asceptic.
C. Inform the client she will need to formula feed her newborn until she has received antibiotics for 24 hr. This is incorrect. Breastfeeding is usually safe with most antibiotics, including clindamycin, and mothers with postpartum infections can typically continue breastfeeding unless advised otherwise by the provider.
D. Initiate contact precautions. Contact precautions are not necessary unless the client has an identified or suspected infection that is transmissible by direct contact (e.g., MRSA). Standard precautions are sufficient for routine postpartum care and suspected endometritis.
E. Monitor the height and tone of the client’s fundus. The fundus is tender and was initially boggy, indicating risk for uterine atony or subinvolution. Monitoring tone and height helps detect complications such as hemorrhage or infection.
F. Instruct the client to wash her hands before and after changing her perineal pad. Hand hygiene is essential to prevent the spread of infection to the perineal area or incision and to promote general postpartum hygiene.
G. Encourage the client to maintain a semi-Fowler’s position to enhance uterine drainage. This position helps promote lochia drainage, reduce uterine pooling, and may help with comfort and resolution of infection by improving uterine drainage.
Correct Answer is D
Explanation
A. "You should take a second dose if there is no relief within fifteen minutes after the initial dose." The second dose of sumatriptan should not be taken sooner than 2 hours after the first dose if there is no relief or if the migraine returns. Taking it too soon increases the risk of adverse effects.
B. "You may experience low blood pressure while taking this medication." Sumatriptan more commonly causes hypertension, not hypotension. It can cause vasoconstriction, which may elevate blood pressure and poses risks, especially in clients with cardiovascular disease.
C. "You should have complete relief in six hours after taking this medication." Relief from sumatriptan is often experienced within 1–2 hours after administration. While not all clients achieve complete relief, the medication acts quickly, and six hours is not the expected timeframe.
D. “You may experience muscle cramps as a potential adverse effect of the medication." Muscle cramps or tightness in the chest, neck, or limbs can occur due to vasoconstriction caused by sumatriptan. This is a known side effect and should be reported if severe or persistent.
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