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 D
Explanation
A. Constipation can be caused by various factors including pain medications, but it is not a direct indicator of unrelieved pain.
B. Difficulty swallowing may not be directly related to unrelieved pain from the herniated disc.
C. Urinary retention is more likely related to the anesthesia effects or nerve compression in the spine rather than unrelieved pain.
D. Correct. Clenched teeth or grimacing are often signs of unrelieved pain. These nonverbal cues can be important indicators of discomfort in patients who might not verbally express their pain.
Correct Answer is C
Explanation
A. Potatoes are generally considered safe for toddlers to consume, as they are usually cooked until they are soft and easy to chew.
B. Oranges can be a choking hazard if not cut into small, manageable pieces, but they are less likely to cause choking than some other foods.
C. Correct. Grapes are small and round, making them a significant choking hazard for toddlers.
They can easily become lodged in a toddler's airway.
D. Corn kernels can also be a choking hazard for toddlers, especially if they are not chewed thoroughly or if the toddler eats them directly off the cob.
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