A nurse is caring for an older adult client who is disoriented and has a history of falls. Which of the following actions should the nurse take? (Select all that apply.)
Apply an ambulation alarm to the client's leg.
Obtain a prescription to restrain the client PRN.
Instruct the client in the use of the call light.
Raise all side rails on the client's bed.
Check on the client hourly.
Correct Answer : A,C,E
Rationale:
A. Applying an ambulation alarm can help alert staff if the client tries to move independently, thus reducing the risk of falls.
B. Restraints should only be used as a last resort and require a physician’s order. They should not be used routinely for fall prevention.
C. Instructing the client in the use of the call light empowers them to request assistance, which can help prevent falls.
D. Raising all side rails can be considered a restraint and may increase the risk of falls or injury. It is not a recommended practice for fall prevention.
E. Checking on the client hourly ensures ongoing monitoring and timely intervention if needed, which is effective in preventing falls.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Rationale:
A. Providing a back rub can be done by an AP, as it does not require specialized nursing skills.
B. Transporting a client is an appropriate task for an AP if the client is stable.
C. Performing oral hygiene for a postoperative client can be managed by an AP with supervision.
D. Removing and cleaning the cannula of a new tracheostomy requires specific skills and knowledge that only a licensed nurse should perform to avoid complications.
Correct Answer is {"dropdown-group-1":"C","dropdown-group-2":"A"}
Explanation
Provide continuous monitoring of this client: Continuous monitoring is essential to ensure the client's safety while in seclusion, particularly given their agitated and potentially harmful behavior.
Obtain provider prescription for seclusion or restraints: It's necessary to ensure that the use of seclusion is appropriately authorized and documented, following the facility's protocol and legal requirements.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.