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 D

Explanation

Answer is: d. Reposition the client.

Explanation: Repositioning the client can help alleviate pain by redistributing pressure and promoting comfort. Since the client's pain level is relatively low (2 on a scale of 0 to 10), this non-pharmacological intervention is an appropriate initial action.

Choice a. is wrong because maintaining the client on bed rest is not an appropriate action for a pain level of 2. Instead, the nurse should encourage the client to mobilize and perform appropriate exercises to prevent complications related to immobility.

Choice b. is wrong because applying a warm, moist compress to the incision area might not be the best action for a client who is 24 hours postoperative, as it could increase the risk of infection and cause discomfort. Cold compresses are often used in the initial postoperative period to reduce swelling and promote comfort.

Choice c. is wrong because administering an additional dose of pain medication is not necessary at this point, as the client's pain level is relatively low. The nurse should consider non-pharmacological interventions first and reassess the client's pain level to determine the need for further pain relief.

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.

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.

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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

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