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
A. Correct. Overhearing private client information being discussed by staff members violates the client's right to privacy and confidentiality. The nurse should address the situation immediately and instruct the assistive personnel to stop the conversation.
B. Incorrect. While documenting the event in the client's progress notes may be necessary, addressing the inappropriate behavior of the assistive personnel takes precedence.
C. Incorrect. Informing the client about the conversation is not necessary and may further compromise the client's sense of privacy.
D. Incorrect. Submitting an incident report to the risk manager might be necessary, but the immediate action should be to stop the conversation and address the breach of confidentiality.
Correct Answer is D
Explanation
A. Remaining in bed until falling asleep can worsen insomnia and create negative associations with the bed.
B. While maintaining a consistent sleep schedule is important, sleeping longer on the weekends can disrupt the circadian rhythm.
C. Keeping the television volume low can help with sleep, but it might not directly address the underlying issue of trouble falling asleep.
D. Correct. Regular exercise, especially during the day, can help regulate sleep patterns and improve the ability to fall asleep at night.
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