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 B

No explanation

A. Rolls soiled linen with the clean side in before placing it in the laundry bag. B. Cleans a blood spill with chlorine bleach. C. Performs hand hygiene with hands at elbow level. D. Instructs a female client to wipe the perineal area from back to front.

Correct Answer is B

Explanation

The correct answer is choice B, which cleans a blood spill with chlorine bleach. This is an appropriate action for infection control because bleach is an effective disinfectant that can kill most pathogens, including bloodborne viruses such as HIV and hepatitis B and C.

A. Rolling soiled linen with the clean side in it before placing it in the laundry bag is not the correct answer because it can spread pathogens and cause cross-contamination.

Performing hand hygiene with hands at elbow level is not the correct answer because it is not the correct technique for hand hygiene, which involves washing hands with soap and water or using an alcohol-based hand sanitizer.

Instructing a female client to wipe the perineal area from back to front is not the correct answer because it can cause contamination of the urethra and increase the risk of urinary tract infections.

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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?

Nursing Test Bank

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Explanation

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