A nurse is working a night shift and caring for several clients at risk for falls. Which of the following actions should the nurse take? (Select all that apply.)

Instruct the clients to use the call light.

Move overbed tables away from the bed.

Place a fall risk wristband on each of the clients.

Perform client checks every 4 hr.

Keep the clients' rooms dark.

Answer and Explanation

Correct Answer : A,B,C,D

A. Instruct the clients to use the call light.

Encouraging clients to use the call light enables them to request assistance when needed, reducing the risk of falls if they need help to move or get out of bed.

B. Move overbed tables away from the bed.

Clearing the area around the bed, including overbed tables, reduces obstacles and potential hazards that clients might trip over or get tangled in.

C. Place a fall risk wristband on each of the clients.

Identifying clients at risk for falls by using wristbands helps alert all healthcare staff to take necessary precautions and provide appropriate assistance to prevent falls.

D. Perform client checks every 4 hr.

Regular client checks allow the nurse to monitor their condition, reposition them if necessary, assist with toileting needs, and ensure they're safe, especially during the night when falls might be more likely.

E. Keep the clients' rooms dark.

Keeping the room dimly lit during the night can help clients sleep better but should still provide enough light for safe movement. Complete darkness might increase the risk of falls if clients need to move around.

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Correct Answer is D

Explanation

A. Provide client care as assigned:

While it is essential to be flexible and adaptable, patient safety is a priority. If the nurse is not familiar with certain skills or techniques and believes it could compromise patient safety, blindly providing care may not be the best option.

B. Make a formal complaint to the nursing manager:

Making a formal complaint should not be the initial step. It is better to explore other options before escalating the situation to a higher level.

C. Request the charge nurse to modify the assignment:

This is a reasonable option. The nurse can communicate concerns to the charge nurse and request modifications to the assignment based on their skills and competency.

D. Ask another nurse to trade assignments:

This is the most immediate and practical solution. If there's another nurse available who is more familiar with the required skills, trading assignments can ensure that the patient receives appropriate care from a nurse with the necessary expertise.

A. Concurrent treatment for GERD B. History of breast cancer C. History of dermatitis D. Multiple hospitalizations for COPD

Correct Answer is B

Explanation

A. Concurrent treatment for GERD (gastroesophageal reflux disease) is not typically a contraindication for hormone replacement therapy. However, it's essential to assess the specific details of the client's medical history and medications to ensure safe use.

B. A history of breast cancer is a significant contraindication for hormone replacement therapy. Estrogen, a component of many HRT regimens, can stimulate the growth of certain types of breast cancer. Therefore, HRT is generally avoided in individuals with a history of breast cancer.

C. A history of dermatitis is not typically a contraindication for hormone replacement therapy. However, individual circumstances should be considered, and any concerns related to skin conditions should be discussed with the healthcare provider.

D. Multiple hospitalizations for COPD (chronic obstructive pulmonary disease) may not be a direct contraindication for hormone replacement therapy, but the overall health status and individual medical history should be carefully considered before initiating HRT.

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A nurse is working a night shift and caring for several clients at risk for falls. Which of the following actions should the nurse take? (Select all that apply.)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A float nurse is given a client assignment that requires the use of unfamiliar skills and techniques. Which of the following actions should the nurse take?

Correct Answer is D

Explanation

A nurse is caring for a client who is experiencing menopausal symptoms and requests information about hormone replacement therapy (HRT). Which of the following items in the client's health history is a contraindication for hormone replacement therapy?

Correct Answer is B

Explanation

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