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 ["2"]

Explanation

To calculate the dosage of lorazepam, the nurse needs to use the formula D/H x Q, where D is the desired dose, H is the dose on hand, and Q is the quantity. In this case, D is 2 mg, H is 1 mg, and Q is 1 tablet. Plugging these values into the formula, we get:

2 mg / 1 mg x 1 tablet = 2 tablets

Therefore, the nurse should administer 2 tablets of lorazepam to the patient.

A. Salmeterol B. Diazepam C. Misoprostol D. Penicillin G

Correct Answer is B

Explanation

A. Salmeterol:

Salmeterol is a long-acting beta-agonist bronchodilator used for respiratory conditions. While it does not directly cause sedation, the individual response may vary, and caution should be taken if the client experiences dizziness or lightheadedness.

B. Diazepam:

Diazepam is a medication that belongs to the benzodiazepine class and can cause sedation, drowsiness, and impaired coordination. These side effects increase the risk of falls, especially in older adults. Fall precautions may include measures such as bed alarms, non-skid socks, and close monitoring when the client is ambulating.

C. Misoprostol:

Misoprostol is a medication used to prevent gastric ulcers, and it does not typically cause sedation or affect coordination.

D. Penicillin G:

Penicillin G is an antibiotic and does not have sedative effects that would necessitate fall precautions.

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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 nurse is preparing to administer lorazepam 2 mg PO. Available is lorazepam 1 mg tablets. How many tablets should the nurse administer? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.)

Correct Answer is ["2"]

Explanation

A nurse is reviewing a client's medication administration record. For which of the following medications should the nurse place the client on fall precautions?

Correct Answer is B

Explanation

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