As a nurse prepares an older adult client for bed on the first night of her hospital stay, the client says, "I am afraid that I may fall getting to the bathroom during the night. I tend to get a bit disoriented in new surroundings." Which of the following actions should the nurse take?
Offer to request a prescription for an indwelling urinary catheter.
Keep a night light on in the client's room.
Put the side rails up and tell the client to call for assistance to the bathroom.
Limit the client's fluid intake in the evening.
The Correct Answer is B
A. Offer to request a prescription for an indwelling urinary catheter.
Indwelling urinary catheters come with their own set of risks and complications. It is generally not recommended to use them solely for the purpose of preventing falls unless there are other medical indications for their use. Catheters increase the risk of infection and other complications, and their use should be based on clear medical necessity.
B. Keep a night light on in the client's room.
This option directly addresses the client's concern about falling during the night. Providing a night light in the room helps to alleviate disorientation, making it safer for the client to navigate to the bathroom. It is a practical and non-invasive intervention.
C. Put the side rails up and tell the client to call for assistance to the bathroom.
While using side rails can be a fall prevention measure, it's important to consider that they are not without risks. Side rails can lead to entrapment or injury if not used appropriately. In addition, telling the client to call for assistance is good advice, but relying solely on this instruction may not address the immediate concern of disorientation in new surroundings.
D. Limit the client's fluid intake in the evening.
While limiting fluid intake in the evening might reduce the frequency of bathroom trips, it is not the most appropriate response to the client's concern. Dehydration can lead to other health issues and should not be used as the primary strategy for fall prevention.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["2"]
Explanation
To calculate the number of tablets that the nurse should administer, the nurse needs to divide the prescribed dose by the available dose.
In this case, the prescribed dose is aspirin 650 mg PO and the available dose is aspirin 325 mg tablets.
Therefore, the nurse should divide 650 by 325, which gives 2.
Therefore, the nurse should administer 2 tablets of aspirin 325 mg PO.
Correct Answer is D
Explanation
A. It is not permissible because the provider should disclose laboratory results or findings to a client:
While it is true that the provider should disclose laboratory results or findings to the client, the nurse, in this case, should not be accessing the information on behalf of the sibling without proper authorization.
B. It is permissible because the client's sibling made the request:
Even if the sibling made the request, accessing a client's health information without proper authorization is a violation of privacy and confidentiality.
C. It is permissible because the sibling has paid for the service:
Payment for services does not automatically grant access to health information. Protected health information (PHI) is subject to privacy laws, and access should be granted only to those authorized to receive it.
D. It is not permissible because there is no nurse-client relationship between the sibling and nurse:
This is the correct explanation. The nurse should not access a client's health information, even if it is a family member, without proper authorization. The absence of a nurse-client relationship with the sibling does not justify accessing the client's health information.
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