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

Answer and Explanation

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.

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Correct Answer is C

Explanation

A. Slurred speech is not a common adverse effect of gentamicin.
B. Hypotension is not a common adverse effect of gentamicin.
C. Correct. Gentamicin is an aminoglycoside antibiotic known for its potential to cause hearing loss (ototoxicity..
D. Constipation is not a common adverse effect of gentamicin.

A. Oxygen saturation level B. Tremors C. Current level of consciousness D. Heart rate E. Chronic health condition F. Respiratory rate

Correct Answer is ["A","B","F"]

Explanation

A. Oxygen saturation level: The client is restless, not following commands, and has labored respirations with crackles and wheezes in the breath sounds. Monitoring the oxygen saturation level is essential to assess the client's respiratory status and oxygenation.
B. Tremors: The client has tremors in their hands. Considering the client's history of Parkinson's disease, changes in tremors should be monitored and addressed promptly.
C. The immediate concern is addressing the respiratory distress.
D. Heart rate may also be monitored, but it's not as critical in this context.
E. Chronic health conditions are relevant for the overall care plan, but they do not require immediate intervention as compared to respiratory and tremor issues.
F. Respiratory rate: The client has labored respirations and abnormal breath sounds (crackles and wheezes). Monitoring the respiratory rate is important to evaluate the client's breathing pattern and respiratory distress.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is collecting data from a client who has pyelonephritis and is receiving gentamicin via IV Infusion. Which of the following manifestations should the nurse identify as an adverse effect of the treatment?

Correct Answer is C

Explanation

Correct Answer is ["A","B","F"]

Explanation

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