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

A. This is not necessary for a colonoscopy. A clear liquid diet for a shorter period, usually 12-24 hours, is sufficient.

B: The provider does not schedule another procedure to remove any polyps during the colonoscopy; they may be removed during the procedure or later.

C: This is a standard bowel preparation instruction for colonoscopy to ensure a clear view of the colon during the procedure.

D: While enemas may be part of bowel preparation, they are usually administered closer to the procedure, not 2 days in advance.

A. Elevate the head of the client's bed for 1 hr after the feeding. B. Administer the feeding solution at a cold temperature. C. Rotate the jejunostomy tube once per day D. Flush the tube with 90 mL of sterile water before and after the feeding.

Correct Answer is A

Explanation

Elevate the head of the client's bed for 1 hr after the feeding. This is because elevating the head of the client's bed to at least 30 degrees can help prevent aspiration and gastric reflux.

Choice B is incorrect because administering the feeding solution at a cold temperature can cause discomfort and diarrhea.

Choice C is incorrect because rotating the jejunostomy tube once per day can cause irritation and trauma to the stoma site.

Choice D is incorrect because flushing the tube with 90 mL of sterile water before and after the feeding is not necessary as long as the tube is adequately flushed before and after each feeding.

The explanation for why the other choices are not answered: B – Administering the feeding solution at a cold temperature can cause discomfort and diarrhea, so it should not be done. C – Rotating the jejunostomy tube once per day can cause irritation and trauma to the stoma site, so this is not the correct action. D – Flushing the tube with 90 mL of sterile water before and after the feeding is unnecessary to do as long as the tube is adequately flushed before and after each feeding. Thus, this is not the correct answer.

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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

Naxlex Comprehensive Predictor Exams

A nurse is reinforcing teaching with a client who will undergo a colonoscopy the following week. Which of the following instructions should the nurse include?

Correct Answer is C

Explanation

A nurse is caring for a client who is receiving intermittent bolus enteral feedings through a jejunostomy tube. Which of the following actions should the nurse take?

Correct Answer is A

Explanation

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