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

Answer and Explanation

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.

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Correct Answer is B

Explanation

The correct answer is B.

Initiate droplet precautions. The rationale is that RSV is a highly contagious viral infection that causes respiratory tract inflammation and can spread through respiratory droplets from coughing or sneezing. The nurse should wear a mask and gloves when caring for the preschooler and isolate them from other children to prevent transmission.

A. Increased urinary frequency B. Dry cough C. Metallic taste in mouth D. Excessive sweating

Correct Answer is D

Explanation

Choice A reason:

Increased urinary frequency Increased urinary frequency is not a typical adverse effect of sertraline. However, some individuals may experience changes in urinary habits due to various factors, but it is not directly related to sertraline use.

Choice B reason

Dry cough Dry cough is not a commonly reported adverse effect of sertraline. Cough is not a typical symptom associated with this medication.

Choice C reason

Metallic taste in the mouth While some individuals may experience changes in taste as a side effect of sertraline, a metallic taste in the mouth is not one of the commonly reported adverse effects. Taste changes are usually mild and temporary.

Choice D reason

Sertraline is a selective serotonin reuptake inhibitor (SSRI) antidepressant commonly used to treat conditions like depression, anxiety disorders, and obsessive-compulsive disorder. While most individuals tolerate sertraline well, it can cause certain adverse effects, and excessive sweating (also known as diaphoresis) is one of them.

Excessive sweating is a common side effect of sertraline and other SSRIs. It can manifest as increased sweating during the day or night, even in cooler environments. The degree of sweating can vary among individuals, and some may experience it more than others.

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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

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Correct Answer is B

Explanation

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Correct Answer is D

Explanation

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