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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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["2"]
Explanation
To calculate the dosage of amoxicillin, the nurse needs to divide the prescribed dose by the available dose and multiply by one tablet. In this case, the prescribed dose is 500 mg and the available dose is 250 mg. Therefore, the nurse should administer:
(500 mg / 250 mg) x 1 tablet = 2 tablets
The nurse should document the administration of amoxicillin in the patient's chart and monitor for any adverse reactions or allergies.
Correct Answer is B
Explanation
A. "The doctor can best help you with that after your physical examination."
This response implies that a physical examination is necessary before discussing contraception, which may not be accurate. Contraceptive counseling can often occur without a physical examination, and the nurse can provide initial guidance based on the information available.
B. "Before I can help you with that question, I need to know more about your sexual activity."
This response is appropriate because it acknowledges the need for more information to provide personalized advice. It respects the individual's privacy while recognizing that different contraceptive methods may be suitable based on factors like sexual activity, health history, and personal preferences.
C. "You are so young. Are you sure you are ready for the responsibilities of a sexual relationship?"
This response may come across as judgmental and could potentially discourage open communication. It's essential to maintain a non-judgmental and supportive attitude when discussing sexual health with adolescents. Instead of questioning their readiness, the focus should be on providing accurate information and support.
D. "Because of your age, we need your parents' consent for an examination, and then we'll talk."
This response may not be appropriate as it suggests a potential barrier to seeking advice about contraception. Many jurisdictions allow adolescents to receive confidential reproductive health services, including contraception, without parental consent. Encouraging open communication and respecting confidentiality is crucial in supporting adolescents' access to reproductive healthcare.
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