A nurse is preparing a staff training on fall prevention for clients who have moderate dementia. Which of the following strategies should the nurse include?

Delegate scheduled checks to assistive personnel.

Ensure all the side rails are up when the client is in bed.

Collaborate with a provider to request PRN standard prescriptions for sedatives.

Keep televisions on around the unit for distraction.

Answer and Explanation

The Correct Answer is A

A. Delegate scheduled checks to assistive personnel: Regular, scheduled checks help monitor clients with moderate dementia for signs of restlessness, wandering, or unsafe behaviors that could lead to falls. Delegating this task ensures consistent supervision and enhances safety.

B. Ensure all the side rails are up when the client is in bed: Raising all side rails can actually increase the risk of injury, as clients with dementia may attempt to climb over them, leading to falls or entrapment. Side rails should be used judiciously and according to safety guidelines.

C. Collaborate with a provider to request PRN standard prescriptions for sedatives: Routine use of sedatives can increase confusion, dizziness, and fall risk in clients with dementia. Nonpharmacologic fall prevention strategies are preferred whenever possible.

D. Keep televisions on around the unit for distraction: Continuous background noise or television can be overstimulating and may increase agitation in clients with dementia, potentially increasing the risk of falls rather than preventing them.

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Correct Answer is D

Explanation

A. Interpret the client's need for pain medication: Determining the need for analgesia requires professional nursing judgment and assessment, which is outside the AP’s scope of practice. The nurse must evaluate pain and make medication decisions.

B. Change a sterile dressing on a client's open incisional wound: Sterile dressing changes involve invasive procedures and assessment of wound healing, which are nursing responsibilities. APs can assist with non-sterile care but cannot perform sterile interventions independently.

C. Educate a client on the use of a glucometer: Patient education involves teaching, assessing understanding, and clinical judgment, all of which require nursing expertise. APs can reinforce teaching but cannot independently instruct clients on medical device use.

D. Perform cardiopulmonary resuscitation on a client: CPR is a basic life-saving procedure that APs are trained and authorized to perform in emergencies. This task falls within the AP’s scope of practice and can be done under general supervision until advanced help arrives.

A. Clean the insertion site with betadine. B. Flush the catheter with sterile water. C. Use a 5-mL syringe to flush the catheter. D. Wear sterile gloves when providing site care.

Correct Answer is D

Explanation

A. Clean the insertion site with betadine: While povidone-iodine (Betadine) can be used, current guidelines recommend using chlorhexidine for central line site care because it is more effective in preventing catheter-related bloodstream infections. Using betadine is not the preferred standard of care.

B. Flush the catheter with sterile water: Central venous catheters should be flushed with sterile saline, not sterile water, to maintain patency and avoid hemolysis or electrolyte imbalance. Flushing with water can damage blood cells and the catheter.

C. Use a 5-mL syringe to flush the catheter: A minimum of a 10-mL syringe is recommended when flushing a central venous catheter because smaller syringes generate excessive pressure that can damage the catheter. Using a 5-mL syringe increases the risk of catheter rupture.

D. Wear sterile gloves when providing site care: Sterile technique is required when performing central line site care to prevent infection. Wearing sterile gloves protects the client from pathogens and is a critical step in maintaining asepsis during dressing changes and catheter maintenance.

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A nurse is preparing a staff training on fall prevention for clients who have moderate dementia. Which of the following strategies should the nurse include?

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Naxlex Comprehensive Predictor Exams

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