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.

Answer and Explanation

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.

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Correct Answer is D

Explanation

Rationale:

A. Telling other nurses is useful for team morale but does not directly recognize the AP.

B. Detailing contributions to the manager is valuable but can be done after initial direct recognition.

C. Nominating for an award is an excellent formal recognition but should follow immediate feedback.

D. Giving direct positive feedback immediately acknowledges the AP’s efforts and encourages continued good performance.

A. Nonmaleficence B. Veracity C. Autonomy D. Fidelity

Correct Answer is A

Explanation

A. Nonmaleficence: By completing a critical care and emergency nursing course before transferring to the ICU, the nurse is ensuring they are adequately prepared to care for critically ill clients. This action minimizes the risk of harm caused by a lack of knowledge or skill, demonstrating adherence to the principle of nonmaleficence.

B. Veracity: Veracity refers to truthfulness and honesty in interactions with clients and colleagues. While important, this scenario does not focus on providing truthful information.

C. Autonomy: Autonomy refers to respecting a client's right to make decisions about their care. This scenario does not involve supporting or promoting client decision-making.

D. Fidelity: Fidelity refers to being faithful to commitments and promises made to clients or the profession. While the nurse is demonstrating professional responsibility, this scenario aligns more closely with nonmaleficence than fidelity.

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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.)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A charge nurse is working with an assistive personnel (AP) who provides excellent care to clients and is an effective team member. Which of the following actions should the nurse take first to recognize the AP's contributions to client care?

Correct Answer is D

Explanation

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Correct Answer is A

Explanation

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