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.
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Related Questions
Correct Answer is D
Explanation
A. Incorrect. Applying an ice pack to the affected extremity is not recommended for a client with deep vein thrombosis, as it could potentially exacerbate the condition by promoting vasoconstriction.
B. Correct. Administering aspirin for pain relief is an appropriate action for a client with deep vein thrombosis. Aspirin has anti-inflammatory and analgesic properties and can help manage pain associated with thrombosis.
C. Incorrect. Massaging the affected extremity is contraindicated for a client with deep vein thrombosis, as it can dislodge the clot and pose a risk of embolization.
D. Incorrect. Initiating bed rest is not recommended for a client with deep vein thrombosis.
Encouraging early ambulation and mobilization can help prevent complications such as thrombus extension and pulmonary embolism.
Correct Answer is B
Explanation
A. Incorrect. Human papillomavirus (HPV. is a common sexually transmitted infection, but it is not typically a reportable infection to the state health department.
B. Correct. Neisseria gonorrhoeae is a reportable sexually transmitted infection, and healthcare providers are required to report cases to the state health department for tracking and intervention purposes.
C. Incorrect. Impetigo contagiosa is a bacterial skin infection, but it is not typically a reportable infection to the state health department.
D. Incorrect. Sarcoptes scabiei is the parasite that causes scabies, a skin condition, but it is not typically a reportable infection to the state health department.
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