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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
The correct answer is choice a. Wear shoes with rubber soles.
Choice A rationale:
Wear shoes with rubber soles () - Quiet footwear minimizes noise disruption during sleep hours, promoting a better sleep environment.
Choice B rationale:
Conduct change of shift reports near the clients’ rooms () - Conducting reports near rooms creates noise and disrupts sleep. It’s best done in designated areas away from patients.
Choice C rationale:
Open curtains between clients in semi-private rooms () - Privacy and individual light control are crucial for sleep. Open curtains can disrupt a client’s sleep cycle.
Choice D rationale:
Turn on overhead lights briefly when checking IV lines () - Bright lights suppress melatonin production, a hormone vital for sleep. Using alternative light sources or dimmed lighting minimizes sleep disruption.
Correct Answer is C
Explanation
A. Incorrect. Justice refers to fairness and equitable treatment of clients. While important, it does not specifically pertain to the nurse's communication about medication adverse effects.
B. Incorrect. Autonomy refers to the client's right to make decisions about their own care and treatment. While truthfully communicating about medication's adverse effects supports autonomy, veracity is the ethical concept specifically related to truthfulness.
C. Correct. Veracity is the ethical concept of truthfulness and honesty in communication. When the nurse communicates truthfully about the potential adverse effects of the medications, they are demonstrating veracity.
D. Incorrect. Beneficence refers to the duty to do good and promote the well-being of the client.
While important, it is not the ethical concept specifically related to truthful communication about medication's adverse effects.
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