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. An incident report should be completed for any unintended event or situation that could have resulted or did result in harm to a patient. Administering the wrong dose of medication falls under this category.

B. Incorrect. The nursing care plan is a comprehensive outline of a patient's care needs and interventions and is not the appropriate place to document a medication error.

C. Incorrect. The provider's progress notes are meant to document the patient's condition, care, and progress, but they are not used to document medication errors.

D. Incorrect. The controlled substance inventory record is used to track the dispensing and administration of controlled substances, not to document medication errors.

A. Tingling of the scalp B. Voice alteration C. Neck pain D. Temporary memory loss

Correct Answer is D

Explanation

A. Incorrect. Tingling of the scalp is not a common adverse reaction following electroconvulsive therapy (ECT.
B. Incorrect. Voice alteration is not a common adverse reaction following ECT.
C. Incorrect. Neck pain is not a common adverse reaction following ECT.
D. Correct. Temporary memory loss is a common adverse reaction following ECT. Some clients may experience confusion and memory deficits immediately after the procedure, but these effects are typically temporary and resolve as the client recovers from the treatment.

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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 is caring for a client who has a prescription for acetaminophen 300 mg with codeine 30 mg, 1 tablet every 3 to 4 hr. PRN for pain. The nurse inadvertently administered 2 tablets to the client. In which of the following locations should the nurse document this client care incident?

Correct Answer is A

Explanation

A nurse is reinforcing teaching with a client who is about to undergo electroconvulsive therapy. The nurse should explain to the client which of the following adverse reactions can occur following the procedure.

Correct Answer is D

Explanation

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