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. "I will keep my walker at the end of my bed":

While keeping the walker at the end of the bed may be convenient, it is not a safety measure in itself. It's important for the client to use the walker as needed for support and stability, especially during ambulation.

B. "I will place an area rug at the entry of my bathroom":

Placing area rugs can be a fall hazard, as they may cause tripping. It is generally recommended to have non-slip surfaces, especially in areas prone to moisture like the bathroom.

C. "I will keep the fluorescent ceiling light on in my room at night":

While having adequate lighting is important for preventing falls, leaving a fluorescent ceiling light on all night may not be necessary. Using night lights or low-intensity lighting may be more appropriate to prevent disruption of sleep.

D. "I will place a bath seat in my shower to use when I bathe":

This is the correct statement. Using a bath seat in the shower provides stability and reduces the risk of slipping and falling while bathing. It is a proactive measure to enhance safety in the bathroom.

A. A client who has had prolonged diarrhea B. A client who has lactose intolerance C. A client who has had radiation therapy for head and neck cancer D. A client who has had a stroke E. A client who is 4 hr postoperative following a leg amputation under general anesthesia

Correct Answer is ["C","D","E"]

Explanation

A. A client who has had prolonged diarrhea:

Prolonged diarrhea is not typically associated with an increased risk of aspiration during eating.

B. A client who has lactose intolerance:

Lactose intolerance primarily affects the ability to digest lactose-containing foods and does not directly increase the risk of aspiration.

C. A client who has had radiation therapy for head and neck cancer:

Radiation therapy to the head and neck can cause damage to the structures involved in swallowing, increasing the risk of aspiration.

D. A client who has had a stroke:

Stroke can affect the coordination of swallowing muscles, leading to dysphagia (difficulty swallowing) and an increased risk of aspiration.

E. A client who is 4 hr postoperative following a leg amputation under general anesthesia:

Postoperative clients under general anesthesia may experience impaired protective airway reflexes, making them prone to aspiration. It's important to monitor these clients closely during the initial recovery period.

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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.)

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Naxlex Comprehensive Predictor Exams

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Correct Answer is D

Explanation

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Correct Answer is ["C","D","E"]

Explanation

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