A nurse working the night shift is caring for an older adult client who has dementia and is at risk for falls. Which of the following actions should the nurse take?

Apply a motion sensor mat to the client's bed.

Move the overbed table away from the bed.

Raise all four side rails while the client is in bed.

Leave the television on in the client's room.

Answer and Explanation

The Correct Answer is A

The correct answer is choice A, apply a motion sensor mat to the client's bed. This is an effective intervention to monitor the client's movements and prevent falls. The mat is placed under the bed sheet and will sound an alarm if the client tries to get out of bed.

Moving the overbed table away from the bed is not the correct answer because it does not prevent falls.
Raising all four side rails while the client is in bed is not the correct answer because it can cause the client to feel trapped and can lead to injuries if they try to climb over the rails.
Leaving the television on in the client's room is not the correct answer because it can be distracting and interfere with the client's sleep.

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Correct Answer is C

Explanation

The correct answer is choice C. Place white tape on the edges of stairs.

Choice A rationale:

While having the furnace inspected is important for safety, it should be done annually, not every two years.Regular inspections help prevent carbon monoxide leaks and ensure the furnace is functioning properly.

Choice B rationale:

Running wires and cords under carpeting is a safety hazard. It can lead to overheating and potentially cause a fire.Additionally, it creates a tripping hazard.

Choice C rationale:

Placing white tape on the edges of stairs is a recommended safety measure.It increases visibility, especially for older adults who may have vision impairments, reducing the risk of falls.

Choice D rationale:

Placing area rugs on wooden floors can be dangerous as they can slip and cause falls.If area rugs are used, they should be secured with non-slip backing or tape.

A. Restrict the diet to clear liquids for 1 to 3 days before the procedure. B. Expect the provider to schedule another procedure to remove any polyps. C. Do not eat or drink anything except water for 12 hours before the procedure. D. Administer enemas 2 days before the procedure. E. None F. None

Correct Answer is A

Explanation

The correct answer is Choice A.

Choice A rationale: A clear liquid diet 1 to 3 days before a colonoscopy minimizes residue in the colon, enhancing mucosal visualization and reducing the risk of missed lesions. Clear liquids include water, broth, tea, and gelatin, which are easily absorbed and leave minimal waste. This dietary preparation complements bowel cleansing agents like polyethylene glycol. Inadequate preparation can obscure polyps or inflammation. Normal stool consistency should be absent during the procedure to ensure optimal diagnostic accuracy.

Choice B rationale: Polypectomy is typically performed during the colonoscopy itself if polyps are detected. Most polyps are removed using snares or biopsy forceps during the same session, reducing the need for a second procedure. Scheduling another procedure is reserved for complex or large lesions requiring advanced techniques. Delaying removal increases the risk of progression to malignancy. Normal colonoscopy findings include pink mucosa and absence of polyps; any deviation warrants immediate intervention when feasible.

Choice C rationale: Restricting intake to only water for 12 hours before the procedure is insufficient and potentially misleading. Colonoscopy preparation requires both dietary modification and pharmacologic bowel cleansing, not just fasting. Water alone does not clear the colon of fecal matter. Additionally, fasting without electrolyte replacement may lead to dehydration and electrolyte imbalance. Normal serum potassium ranges from 3.5 to 5.0 mEq/L; inadequate preparation may cause hypokalemia, especially with laxative use.

Choice D rationale: Enemas are not routinely recommended 2 days before colonoscopy. They may be used adjunctively on the day of the procedure for distal colon cleansing but are insufficient for full bowel preparation. Oral bowel prep agents like polyethylene glycol are preferred for complete evacuation. Enemas only reach the rectosigmoid region and do not cleanse the ascending or transverse colon. Incomplete prep compromises mucosal visualization and diagnostic yield, increasing false-negative rates.

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A nurse working the night shift is caring for an older adult client who has dementia and is at risk for falls. Which of the following actions should the nurse take?

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Naxlex Comprehensive Predictor Exams

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