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 A

Explanation

A. Correct. Lightheadedness upon standing, also known as orthostatic hypotension, can be a common side effect of ACE inhibitors. Advising the client to sit down when experiencing lightheadedness will help prevent falls.
B. Incorrect. Discontinuing the medication without consulting a healthcare provider is not appropriate. Lightheadedness can be managed with strategies like changing positions slowly.
C. Incorrect. Restricting fluid intake is not necessary unless advised by a healthcare provider.
Adequate hydration is important, especially with the use of certain medications.
D. Incorrect. While potassium supplements might be prescribed in some cases with ACE inhibitors, the primary concern in this situation is addressing orthostatic hypotension.

A. Write the information at an 8th-grade reading level. B. Explain medical terminology using basic, one-syllable words. C. Present information from complex to simple. D. Use a 12-point font size.

Correct Answer is A

Explanation

A. Correct. To ensure the information is accessible to a wide audience, it should be written at an 8th-grade reading level, which is suitable for the general population.
B. Using basic, one-syllable words is a good approach, but the reading level should also be considered.
C. Presenting information from complex to simple might be helpful, but starting with simpler concepts is more effective for understanding.
D. While font size is important for readability, the reading level of the content is more critical for comprehension.

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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

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