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. "Use wool blankets on your bed" is not recommended as wool is a flammable material that can pose a risk with oxygen use.

B. "Store unused oxygen tanks horizontally" is not correct; tanks should be stored upright to prevent damage or leakage.

C. "Check your oxygen equipment once each week" is insufficient; equipment should be checked more frequently to ensure safety.

D. "Do not adjust the oxygen flow rate" is correct as clients should not make adjustments without medical advice to ensure proper oxygen levels are maintained.

A. Perform blood glucose monitoring of a client who has a prescription for short-acting insulin prior to breakfast. B. Apply a condom catheter to a client who is incontinent. C. Deliver a clean voided urine specimen to the laboratory. D. Feed a client who has bilateral casts due to upper arm fractures.

Correct Answer is A

Explanation

Rationale:

A. Performing blood glucose monitoring before breakfast is crucial for timely insulin administration and managing diabetes effectively.

B. Applying a condom catheter is important but can generally be done after more urgent tasks.

C. Delivering a clean urine specimen is important but less time-sensitive compared to blood glucose monitoring.

D. Feeding a client is important but may not be as urgent as tasks directly affecting medical management.

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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 nurse is providing discharge teaching for a client who has a new prescription for home oxygen. Which of the following instructions should the nurse include in the teaching?

Correct Answer is D

Explanation

A nurse has received change-of-shift report and is delegating tasks to the assistive personnel (AP). The nurse should tell the AP to complete which of the following tasks first?

Correct Answer is A

Explanation

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