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 A
Explanation
Rationale:
A. Discovery phase is when depositions are typically taken, as this phase involves gathering evidence and information from parties involved.
B. Decision phase occurs after the trial to determine the verdict.
C. Trial phase involves presenting evidence and arguments, but depositions occur earlier during discovery.
D. Complaint phase involves filing the lawsuit and does not include depositions.
Correct Answer is D
Explanation
Rationale:
A. A toddler with asthma and a pulse oximetry reading of 95% is stable and manageable with current oxygen therapy.
B. An adolescent with sickle cell disease is in pain but does not require immediate intervention compared to other scenarios.
C. A toddler with otitis media has a fever and discharge but is not in immediate danger.
D. A school-age child with acute epiglottitis is at high risk for airway obstruction and requires urgent care due to the drooling and absence of spontaneous cough, which are signs of a potentially life-threatening condition.
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