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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Free Nursing Study Resources

Correct Answer is A

Explanation

A. Correct. This instruction helps ensure proper identification of the newborn, reducing the risk of mix-ups.
B. Incorrect. While verifying credentials is important, this action might not be feasible for every nurse and situation.
C. Incorrect. Leaving the newborn unattended is not a safe practice.
D. Incorrect. Carrying the newborn to the nursery might expose the newborn to unnecessary risks and separation.

A. Baked chicken breast B. Orange juice C. Sweet potato D. Cantaloupe

Correct Answer is A

Explanation

A. Correct. Baked chicken breast is relatively low in potassium compared to the other options.
B. Incorrect. Orange juice is high in potassium.
C. Incorrect. Sweet potatoes are high in potassium.
D. Incorrect. Cantaloupe is moderately high in potassium.

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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?

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