A nurse is caring for an older adult client who states, "I am afraid that I may fall while walking to the bathroom during the night." Which of the following actions should the nurse take?

Obtain a bedside commode for the client's use.

Limit the client's fluid intake in the evening.

Put the side rails up and tell the client to call the nurse before voiding.

Leave a nightlight on in the client's room.

Answer and Explanation

The Correct Answer is D

A. Obtain a bedside commode for the client's use: While helpful, this might not address the client's fear of walking in a dark room, and it requires transferring, which could still pose a fall risk.

B. Limit the client's fluid intake in the evening: This can prevent nocturnal trips to the bathroom but doesn't directly address safety if the client needs to get up at night.

C. Put the side rails up and tell the client to call the nurse before voiding: Side rails can sometimes increase fall risk if the client attempts to climb over them. It's more beneficial to ensure a safe environment.

D. Leave a nightlight on in the client's room: This provides adequate lighting, reducing the risk of tripping or falling in the dark, which directly addresses the client's concern about safety while walking to the bathroom.

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Correct Answer is C

Explanation

A. Sheepskin heel pad: A sheepskin heel pad provides cushioning to prevent pressure ulcers but does not prevent plantar flexion contractures as it does not keep the foot in a neutral position.

B. Abduction pillow: An abduction pillow is used to maintain hip abduction and alignment, typically after hip surgery. It does not address foot positioning or prevent plantar flexion.

C. Footboard: A footboard helps maintain the feet in dorsiflexion, preventing plantar flexion contractures. It keeps the feet at a 90-degree angle to the legs, which is essential for preventing contractures.

D. Trochanter roll: A trochanter roll is used to maintain the alignment of the hips and prevent external rotation of the legs. It does not prevent plantar flexion contractures.

A. Document "impaired oxygenation" on the nursing care plan. B. Auscultate the chest for breath sounds. C. Collaborate with the client to form goals. D. Apply supplemental oxygen by face mask as needed.

Correct Answer is B

Explanation

A. Document "impaired oxygenation" on the nursing care plan: While this may be appropriate based on assessment findings, it's premature to document without conducting a thorough assessment first.

B. Auscultate the chest for breath sounds: This is a critical component of assessing respiratory function, especially in a client with pneumonia, to identify abnormal breath sounds such as crackles or diminished breath sounds.

C. Collaborate with the client to form goals: Goal setting typically comes after assessment data is collected and analyzed.

D. Apply supplemental oxygen by face mask as needed: This action should be based on assessment findings indicating the need for oxygen therapy, not assumed without assessment.

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A nurse is caring for an older adult client who states, "I am afraid that I may fall while walking to the bathroom during the night." Which of the following actions should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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