A nurse is reviewing the plan of care for a client who is currently admitted to a medical surgical unit.
Which intervention should the nurse include to promote patient safety and prevent falls?
Keep the bed in the lowest position at all times.
Ensure the room is dimly lit during the daytime hours.
Encourage the client to walk barefoot for better grip.
Place all four side rails in the upright position.
The Correct Answer is A
Patient safety protocols require the application of fall prevention strategies and environmental management. Knowledge of hospital safety standards, mobility mechanics, and the legal implications of restraints is necessary to select interventions that minimize injury risks while maintaining a safe therapeutic environment.
Choice A rationale
Keeping the bed in the lowest position minimizes the vertical distance to the floor, significantly reducing the impact force and potential for injury if a client attempts to exit the bed unassisted. This is a primary fall prevention standard.
Choice B rationale
Dim lighting during daytime hours decreases visual acuity and increases the risk of environmental trips or missteps. Adequate illumination is required for clients to identify obstacles, perceive depth accurately, and navigate their surroundings safely during active hours.
Choice C rationale
Barefoot walking increases the risk of slipping on smooth hospital floor surfaces. Safety protocols mandate non-skid footwear or socks with rubber grips to provide necessary traction and stability, preventing falls related to a lack of foot-to-floor friction.
Choice D rationale
Raising all four side rails is classified as a physical restraint in many jurisdictions and can actually increase injury severity. Clients may attempt to climb over the rails, leading to falls from a much greater height.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Postoperative care for cardiac surgery requires balancing pain management with respiratory function. Knowledge of pulmonary mechanics and the risks of atelectasis is necessary to identify how analgesia facilitates deep breathing and coughing to prevent pneumonia and improve oxygenation.
Choice A rationale
Opioids can cause vasodilation and subsequent hypotension, but reducing blood pressure is not the therapeutic goal of analgesia in this context. While beneficial for cardiac workload, it is not the most critical recovery factor here.
Choice B rationale
Anxiety reduction is a secondary benefit of pain control that improves patient comfort. However, physiological stabilization and the prevention of respiratory complications take precedence over psychological comfort in the immediate postoperative phase after a bypass.
Choice C rationale
Postoperative pain causes guarded, shallow respirations, increasing the risk of lung collapse. Effective analgesia allows the client to perform deep breathing and incentive spirometry, which are vital for maintaining alveolar expansion and preventing secondary infections.
Choice D rationale
Sleep is necessary for cellular repair and overall recovery. While opioids help a patient rest, the primary physiological priority for a bypass patient is maintaining adequate gas exchange through effective ventilation, which requires active respiratory effort.
Correct Answer is B
Explanation
Postoperative monitoring requires identifying deviations from expected healing milestones. Knowledge of surgical site infections and normal physiological parameters is necessary to distinguish between typical postoperative recovery and complications like dehiscence or sepsis that require immediate medical intervention.
Choice A rationale
A respiratory rate of 18/min is within the normal adult range of 12 to 20 breaths per minute. This indicates adequate ventilation and gas exchange following abdominal surgery, suggesting no immediate respiratory distress or pulmonary complications.
Choice B rationale
Yellow-green drainage indicates purulent exudate, suggesting a surgical site infection. This is an abnormal finding 48 hours postoperatively. Normal wound healing should show serosanguinous drainage. Any sign of infection necessitates prompt notification of the healthcare provider.
Choice C rationale
Straw-colored urine is a normal finding indicating adequate hydration and renal perfusion. Standard urinary output should exceed 30 mL/hr. Clear or straw-colored urine suggests that the kidneys are filtering waste products appropriately without hematuria.
Choice D rationale
A blood pressure of 102/66 mm Hg is slightly low but often acceptable postoperatively if the client is asymptomatic. The mean arterial pressure is ≥ 65 mm Hg, which is sufficient for vital organ perfusion and tissue oxygenation.
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