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 B

Explanation

The correct answer is choice b. “I will stop what I am doing and lie down.”

Choice A rationale:

Taking two 325 milligram aspirin tablets at the same time is not the recommended immediate action for chest pain. Aspirin can help in preventing blood clots, but it is not the first step in managing acute angina.

Choice B rationale:

Stopping activity and lying down is the correct initial response to chest pain. This helps reduce the heart’s workload and can alleviate the pain.

Choice C rationale:

Calling the provider after taking one dose of nitroglycerin is important, but it is not the first step. The client should first stop activity and lie down, then take nitroglycerin if prescribed.

Choice D rationale:

Holding the breath and bearing down (Valsalva maneuver) is not appropriate for managing chest pain and can actually increase the heart’s workload, potentially worsening the situation.

A. Maintain abduction of the client's residual limb with a pillow. B. Encourage the client to use the overbed trapeze. C. Caution the client to avoid a prone position while in bed. D. Keep a loose, absorbent dressing over the client's surgical site.

Correct Answer is B

Explanation

A. Incorrect. Maintaining abduction of the residual limb with a pillow is not relevant to promoting mobility and independence for a client with an above-the-knee amputation.
B. Correct. Encouraging the client to use the overbed trapeze can help the client perform upper body movements and reposition independently, which is essential for maintaining mobility.
C. Incorrect. Avoiding a prone position may not be necessary for the client after an above-the-knee amputation and does not directly contribute to mobility and independence.
D. Incorrect. Keeping a loose, absorbent dressing over the surgical site is important for wound care, but it does not directly promote mobility and independence.

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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

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