A nurse is developing a plan of care for a client who is at risk for falls. Which of the following interventions should the nurse include?

Install a bed exit sensor pad at the foot of the client's bed.

Encourage the client to ambulate in compression stockings.

Raise all four side rails for the client at bedtime.

Place a raised toilet seat in the client's bathroom.

Answer and Explanation

The Correct Answer is D

A. Install a bed exit sensor pad at the foot of the client's bed. While a bed exit sensor pad can be useful, it is typically placed on the mattress near the client's hips or lower back, not at the foot of the bed. This placement ensures it detects movement when the client tries to get up, thereby alerting staff to provide assistance.
B. Encourage the client to ambulate in compression stockings. Compression stockings can help with circulation but do not directly address fall prevention. Additionally, they can be slippery on some surfaces, potentially increasing the risk of falls if proper footwear is not used.
C. Raise all four side rails for the client at bedtime. Raising all four side rails is considered a form of restraint and can increase the risk of injury if the client attempts to climb over them. It can also limit the client’s ability to get out of bed independently and safely.
D. Place a raised toilet seat in the client's bathroom. This intervention is appropriate for fall prevention. A raised toilet seat can help clients with mobility issues by making it easier to sit down and stand up, thereby reducing the risk of falls in the bathroom, which is a common site for falls.

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Correct Answer is C

Explanation

A. Shut all the doors on the unit. Shutting doors helps to contain the fire and prevent its spread, but it is not the immediate priority.
B. Initiate the facility's fire alarm. Initiating the fire alarm is crucial for alerting others and ensuring the safety of everyone in the facility. However, immediate action should focus on client safety.
C. Evacuate the client's room. Evacuating the client's room is the priority for ensuring the client's safety in the event of a fire. This action should be taken before attempting to address the fire or other tasks.
D. Extinguish the fire. While extinguishing the fire is important, the immediate priority should be the safety of individuals in the room. Extinguishing the fire can be attempted if safe to do so, but evacuation comes first.

A. Levothyroxine 100 mcg PO qd B. Heparin 15,000 units SC q12h C. Lorazepam 0.5 mg PO qhs D. Acyclovir 400 mg PO tid

Correct Answer is D

Explanation

A. Levothyroxine 100 mcg PO qd "qd" is an error-prone abbreviation and should be avoided. It should be written as "daily."
B. Heparin 15,000 units SC q12h "SC" is an error-prone abbreviation and should be written as "subcutaneously."
C. Lorazepam 0.5 mg PO qhs "qhs" is an error-prone abbreviation and should be written as "at bedtime."
D. Acyclovir 400 mg PO tid This is correctly transcribed using acceptable abbreviations.

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A nurse is developing a plan of care for a client who is at risk for falls. Which of the following interventions should the nurse include?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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