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.

Answer and Explanation

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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Correct Answer is ["D","E"]

Explanation

A. Place the child in prone position:

Placing the child in a prone position (lying face down) during a seizure can obstruct the airway and lead to potential breathing difficulties.

B. Restrain the child:

Restraining a child during a seizure can cause injury or increase agitation. It's important to allow the child to move safely and avoid trying to hold them down.

C. Place a tongue depressor in the child's mouth:

It is not recommended to place anything, including a tongue depressor, in the child's mouth during a seizure. Doing so can cause injury to the child's teeth or oral structures.

D. Clear the area of hard objects:

Removing hard or sharp objects from the vicinity helps prevent injury to the child during the seizure.

E. Loosen restrictive clothing:

Loosening any tight clothing, especially around the neck, chest, or waist, allows the child to breathe more easily and reduces potential constriction during the seizure.

A. Water heater temperature 54.4°C (130° F) B. Electric cords behind furniture C. Bathtub with rails D. Raised toilet seats E. Throw rugs

Correct Answer is ["A","B","E"]

Explanation

A. Water heater temperature 54.4°C (130° F):

This water heater temperature is too high and poses a scalding risk. The recommended temperature setting for water heaters is generally below 49°C (120° F) to prevent burns.

B. Electric cords behind furniture:

Placing electric cords behind furniture can create tripping hazards. It is safer to have cords organized and placed away from areas where the client may walk.

C. Bathtub with rails:

Having a bathtub with rails is a safety feature that can assist the client in getting in and out of the bathtub safely. It is not a safety risk.

D. Raised toilet seats:

Raised toilet seats are often recommended for older adults to facilitate safe and easier use of the toilet. They are not a safety risk when used appropriately.

E. Throw rugs:

Throw rugs can be a tripping hazard, especially for older adults who may have mobility issues. They should be secured or removed to prevent falls.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a child who is having a seizure. Which of the following actions should the nurse take? (Select all that apply.)

Correct Answer is ["D","E"]

Explanation

A home health nurse is conducting a home-safety risk appraisal for an older adult client. Which of the following findings should the nurse identify as a safety risk for the client? (Select all that apply.)

Correct Answer is ["A","B","E"]

Explanation

A nurse is assigning care to an assistive personnel (AP). Which of the following tasks should the nurse delegate to the AP?

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?

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