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
Raises all four side-rails on the client's bed
Locks the wheels on the client's bed
Clears furniture from the path leading to the bathroom
The Correct Answer is B
The correct answer is B. Raising all four side-rails on the client's bed is considered a restraint and can increase the risk of injury if the client tries to climb over them. The nurse should intervene and instruct the AP to lower one or two side-rails and use other fall prevention measures, such as bed alarms, nonskid footwear, and frequent checks.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
The client should check their oxygen equipment at least once daily to ensure proper functioning and safety. The other statements are incorrect and indicate a need for further teaching.
Correct Answer is ["A","C","D"]
Explanation
The correct answer is Choices A, C, and D.
Choice A rationale:
The statement, "I should avoid douching or using tampons for 24 hours after the Pap smear," demonstrates an understanding of post-procedure instructions. It reflects awareness of the need to avoid introducing foreign substances into the vagina immediately after the procedure, which could interfere with the accuracy of the results or increase the risk of infection. By abstaining from douching or tampon use, the client follows recommended guidelines for post-Pap smear care, promoting optimal healing and accuracy of results.
Choice B rationale:
The statement, "I can resume sexual activity as soon as I leave the clinic," is incorrect and does not reflect an understanding of post-Pap smear instructions. Resuming sexual activity immediately after the procedure is not recommended, as it may increase the risk of infection or discomfort. The client should be advised to abstain from sexual activity for a specified period, typically recommended by the healthcare provider, to allow for proper healing and to minimize the risk of complications.
Choice C rationale:
The statement, "It’s normal to experience some mild cramping or spotting after the procedure," demonstrates an understanding of common post-Pap smear symptoms. Mild cramping and spotting are normal reactions to the procedure and are not typically indicative of a problem. By acknowledging these potential side effects, the client shows awareness of what to expect after the Pap smear and is better prepared to manage any discomfort that may arise.
Choice D rationale:
The statement, "I should call the clinic if I experience heavy bleeding or foul-smelling discharge," reflects an understanding of the importance of monitoring for signs of complications post-procedure. Heavy bleeding or foul-smelling discharge may indicate an infection or other issues that require prompt medical attention. By instructing the client to contact the clinic in such situations, the nurse ensures that the client knows how to respond appropriately to potential complications, promoting their overall well-being and timely intervention if necessary.
Choice E rationale:
The statement, "I can expect the results of my Pap smear in about 2-3 days," is incorrect and does not reflect an understanding of the typical timeline for receiving Pap smear results. Pap smear results usually take longer, often a week or more, to be processed and interpreted by the laboratory. Providing accurate information about result expectations is essential for managing the client's post-procedure anxiety and ensuring realistic expectations regarding follow-up.
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