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. The physiologic status of the clients is the most critical factor in assigning tasks, ensuring that clients with more complex needs receive appropriate care.

B. Social relationships are secondary to patient safety and quality of care.

C. Personal comfort level should not influence assignment decisions; patient care needs are the priority.

D. Assigning the most experienced nurse to complex clients is appropriate, but it should be based on client needs rather than just experience alone.

A. A client who is alert and oriented makes an informed decision to leave the hospital against medical advice. The nurse applies restraints to the client to prevent him from leaving. B. A nurse identifies the absence of peripheral pulsation in a casted extremity in the early morning and reports it to the provider in the early afternoon. C. A client who is competent refuses an antidepressant medication. The nurse dissolves the medication in food and administers it to her without her knowledge. D. A nurse finds a client who is on a low-sodium diet eating salted potato chips. The nurse tells the client that she will apply wrist restraints if he does not stop eating the potato chips.

Correct Answer is C

Explanation

Rationale:

B. A nurse identifies the absence of peripheral pulsation in a casted extremity in the early morning and reports it to the provider in the early afternoon might be considered a delay in care but does not necessarily meet the criteria for negligence unless it leads to harm.

C. A client who is competent refuses an antidepressant medication. The nurse dissolves the medication in food and administers it to her without her knowledge is an example of negligence as it violates the client’s autonomy and informed consent.

D. A nurse finds a client who is on a low-sodium diet eating salted potato chips. The nurse tells the client that she will apply wrist restraints if he does not stop eating the potato chips is inappropriate but does not specifically represent negligence; it’s more about improper behavior or coercion.

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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

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