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.
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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Related Questions
Correct Answer is ["D","E"]
Explanation
A. Place the child in prone position:
Placing the child in a prone position (lying face down) during a seizure can obstruct the airway and lead to potential breathing difficulties.
B. Restrain the child:
Restraining a child during a seizure can cause injury or increase agitation. It's important to allow the child to move safely and avoid trying to hold them down.
C. Place a tongue depressor in the child's mouth:
It is not recommended to place anything, including a tongue depressor, in the child's mouth during a seizure. Doing so can cause injury to the child's teeth or oral structures.
D. Clear the area of hard objects:
Removing hard or sharp objects from the vicinity helps prevent injury to the child during the seizure.
E. Loosen restrictive clothing:
Loosening any tight clothing, especially around the neck, chest, or waist, allows the child to breathe more easily and reduces potential constriction during the seizure.
Correct Answer is ["0.5"]
Explanation
To administer lorazepam 1 mg PO to an older adult client who has insomnia and who cannot swallow oral tablets, the nurse should use the lorazepam oral solution 2 mg/mL.
The nurse should calculate the dose by using the formula: Dose (mL) = Desired dose (mg) / Available dose (mg/mL).
In this case, the desired dose is 1 mg and the available dose is 2 mg/mL.
Therefore, the dose (mL) = 1 mg / 2 mg/mL = 0.5 mL.
The nurse should plan to administer 0.5 mL of lorazepam oral solution to the client.
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