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

A. Incorrect. When removing tape, it is best to pull in the direction of hair growth to minimize skin trauma.
B. Correct. When performing a wet-to-dry dressing change, the wound should be cleaned from the center to the outer edges to prevent introducing contaminants into the wound.
C. Incorrect. Wet-to-dry dressings are typically used to debride wounds by allowing the moist dressing to dry and adhere to wound debris. Moistening the dressing before removal can disrupt this process.
D. Incorrect. Sterile gloves are not typically necessary for performing a wet-to-dry dressing change, as it is a clean technique.

A. "I should keep my baby rear-facing in the car seat until she is 2 years old." B. "I should position the car seat's retainer clip at the level of my baby's belly button." C. "I should place my baby in the car seat at a 90-degree angle." D. "I should enable the airbag when my baby is in the front seat of the car."

Correct Answer is A

Explanation

A. Correct. The American Academy of Pediatrics (AAP. recommends keeping infants rear-facing in their car seats until at least the age of 2, or until they reach the maximum weight and height limits recommended by the car seat manufacturer. This is to ensure optimal safety for the child's head, neck, and spine.
B. Incorrect. The retainer clip should be positioned at armpit level to ensure proper fit of the harness straps.
C. Incorrect. While it's important to ensure the proper recline angle of the car seat, the specific angle may vary based on the car seat manufacturer's instructions.
D. Incorrect. It is not safe to enable the airbag when a baby is in the front seat, as airbags can be dangerous for infants due to their size and vulnerability.

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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

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