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

This response indicates that the client understands that sudden jaw pain can be a sign of a heart attack and requires immediate medical attention.

A. "I will take four nitroglycerin sublingual tablets if I have chest pain." This is an incorrect statement because taking four nitroglycerin sublingual tablets can lead to hypotension and can be life-threatening.

B. "I will have hot, dry, and flushed skin if I am having a heart attack." This is an incorrect statement because hot, dry, and flushed skin is not a typical sign of a heart attack.

C. "I will wait 30 minutes before taking action if I have heartburn." This is an incorrect statement because heartburn is not a symptom of angina and waiting 30 minutes to take action can lead to further complications.

Explanation: The client with angina should be educated about the signs and symptoms of a heart attack and when to seek medical attention. Jaw pain is one of the signs of a heart attack, and the client should seek emergency medical attention immediately.

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

A nurse is reinforcing teaching with a client who has angina. Which of the following statements by the client indicates an understanding of the teaching?

Correct Answer is D

Explanation

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

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