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 A

Explanation

Rationale:

A. Check to see if the elbow restraint is in place for an infant who is postoperative from a surgical correction of a cleft palate is a priority to ensure the safety and proper positioning of a vulnerable postoperative patient.

B. Wash the hair of an adolescent who reports extreme fatigue and is scheduled for radiation therapy for the treatment of Hodgkin lymphoma can be done later, as it is not as critical as ensuring the safety of a postoperative infant.

C. Collect a stool sample for ova and parasites from a school-age child is important but not as urgent as checking restraints for a postoperative infant.

D. Engage a toddler in play is important for developmental support but is not as urgent as tasks directly related to patient safety and postoperative care.

A. "What do you have against me? It must be something or you wouldn't be criticizing my care." B. "You shouldn't make accusations. Your nursing care doesn't always set a good example." C. "I feel as though I met the standard of care. Would you tell me more about your concerns?" D. "I am at a loss for words. I always do my best to give good care to my clients."

Correct Answer is C

Explanation

Rationale:

A. "What do you have against me? It must be something or you wouldn't be criticizing my care." is defensive and confrontational, which is not appropriate for assertive communication.

B. "You shouldn't make accusations. Your nursing care doesn't always set a good example." is also defensive and shifts the focus away from addressing the concern directly.

C. "I feel as though I met the standard of care. Would you tell me more about your concerns?" is an assertive response that acknowledges the concern and seeks constructive feedback.

D. "I am at a loss for words. I always do my best to give good care to my clients." is not assertive as it does not address the concern directly or invite constructive discussion.

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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.)

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Naxlex Comprehensive Predictor Exams

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Correct Answer is C

Explanation

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