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. Gathering information about the child's dietary history is the first step to understanding the potential underlying causes of poor intake.
B. Incorrect. Offering nutritious snacks is important, but understanding the child's history is a higher priority.
C. Incorrect. While family presence during mealtimes is important, addressing the child's dietary intake takes precedence.
D. Incorrect. Praise is important but doesn't address the underlying issue of poor dietary intake.

A. Secure the tubing to the child's abdomen. B. Tape the tube to the child's cheek. C. Attach an extension tube to the site's opening prior to use. D. Apply water-soluble lubricant to the site.

Correct Answer is A

Explanation

A.Securing the tubing to the child's abdomen helps prevent accidental dislodgement or pulling of the gastrostomy tube. This can be done using appropriate securing devices, such as adhesive dressings or commercially available tube holders, as recommended by the healthcare provider.

B.Taping the tube to the child's cheek is not a recommended practice. It can cause skin irritation, discomfort, or even accidental removal of the tube. Proper securing of the tube to the abdomen using appropriate devices is the preferred method to prevent dislodgement.

C.Some gastrostomy tubes require an extension set for feeding, especially low-profile devices (e.g., button-type gastrostomy tubes). This extension makes it easier to administer feeds or medications and can be removed afterward. However, this is not typically part of routine site care.

D.Applying lubricant to the site is not necessary or recommended. The gastrostomy tube should be kept clean and dry. If any secretions or debris are present, they should be gently cleaned with mild soap and water, followed by thorough rinsing and drying.

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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 on a pediatric unit is caring for a toddler who has poor dietary intake. Which of the following actions should the nurse take first?

Correct Answer is A

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Correct Answer is A

Explanation

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