A nurse is supervising an assistive personnel (AP. who is caring for a client who is at risk for falls. For which of the following actions by the AP should the nurse intervene?
Assists the client to the bathroom every 2 hr
Locks the wheels on the client's bed
Raises all four side rails on the client's bed
Clears furniture from the path leading to the bathroom
The Correct Answer is C
A. Assisting the client to the bathroom at regular intervals helps prevent falls due to toileting needs.
B. Locking the wheels on the bed prevents unwanted movement and reduces the risk of falls when the client is in bed.
C. Raising all four side rails is considered a restraint, which can increase the risk of falls or injury if the client tries to climb over them. Restraints should be avoided unless absolutely necessary and prescribed by a healthcare provider. In most cases, raising two side rails is sufficient to prevent the client from accidentally rolling out of bed while allowing them to safely exit the bed.
D. Clearing the path from obstacles and furniture reduces the risk of falls by providing a safe and unobstructed route to the bathroom.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Incorrect. Instructing the client to take a brisk walk might exacerbate their symptoms.
B. Incorrect. Checking the client's temperature is not indicated based on the reported symptoms.
C. Incorrect. Providing orange juice might help with low blood sugar but doesn't directly address the reported symptoms.
D. Correct. Positioning the client on their left side can improve blood flow to the heart and uterus, alleviating symptoms of dizziness and racing heart that can occur due to pressure on the vena cava when lying flat on the back.
Correct Answer is D
Explanation
A. Incorrect. Epinephrine is not used to treat hyperglycemia.
B. Incorrect. Epinephrine is not used to treat hand tremors.
C. Incorrect. Epinephrine is not used to treat nausea.
D. Correct. Epinephrine is used to treat severe allergic reactions, including anaphylaxis, which can involve manifestations such as shortness of breath, difficulty breathing, and wheezing.
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