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 A

Explanation

A. "It is a good idea to use the handrails in the bathroom":

This statement reflects an understanding of the importance of using handrails in the bathroom for stability and support, especially when getting in and out of the bathtub or shower. Using handrails can prevent slips and falls in this high-risk area.

B. "I should use chairs without armrests":

Using chairs without armrests may not necessarily contribute to fall prevention. Chairs with armrests can provide additional support and stability when sitting down or getting up.

C. "I should place a throw rug over electrical cords":

Placing a throw rug over electrical cords creates a tripping hazard. It is not a safe practice and contradicts fall prevention measures. Throw rugs should be secured and not placed over cords.

D. "I should get a longer cord for my telephone":

Getting a longer cord for the telephone may not be directly related to fall prevention. It is important to focus on measures that enhance safety and reduce fall risks, such as proper lighting, clear pathways, and the use of assistive devices.

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.

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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 assisting with teaching a class about fall prevention to a group of assisted-living residents. Which of the following statements by a resident indicates an understanding of the teaching?

Correct Answer is A

Explanation

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

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