The client has been admitted and placed on fall precautions. The nurse explains to the patient that interventions for the precautions include: (Select All that Apply)

Placing a high risk for falls armband on the patient

Checking on the patient once a shift

Keep the bed in the lowest position

Placing all four side rails in the "up" position

Maintain call light within reach of the patient

Answer and Explanation

Correct Answer : A,C,E

A. Placing a high risk for falls armband on the patient: An armband alerts all healthcare providers to the patient's fall risk, helping to ensure appropriate precautions are taken.
B. Checking on the patient once a shift: This is not sufficient; patients on fall precautions should be checked more frequently, such as every hour or according to the facility's protocol, to ensure their safety.
C. Keep the bed in the lowest position: Keeping the bed at its lowest position reduces the risk of injury from falls and helps ensure the patient can easily get in and out of bed.
D. Placing all four side rails in the "up" position: Using all four side rails is not recommended as it can increase the risk of entrapment and may not be effective in preventing falls. Side rails should be used appropriately and in accordance with safety protocols.
E. Maintain call light within reach of the patient: Ensuring the call light is within reach helps the patient call for assistance if needed, which can help prevent falls.

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Correct Answer is D

Explanation

A. 214: Although this is a negative-pressure room, it is semi-private, which is not ideal for clients with suspected tuberculosis or similar conditions requiring isolation due to airborne transmission.
B. 212: This is a positive-pressure room, which is not suitable for clients with suspected airborne infections, as it could potentially spread the infection to other areas.
C. 216: This is a private, positive-pressure airflow room, which is not appropriate for the client with suspected airborne infection due to potential cross-contamination risks.
D. 208: This is a private, negative-pressure airflow room, which is ideal for clients with suspected airborne infections, such as tuberculosis. Negative-pressure rooms prevent the spread of airborne pathogens to other areas.

A. Administer medication for high blood pressure B. Reposition the client every 2 hours C. Starting IV antibiotics D. Administering medication for pain E. Administering medication for pain

Correct Answer is B

Explanation

A. Administer medication for high blood pressure: Administering medication generally requires a physician's order and is not considered an independent nursing action.
B. Reposition the client every 2 hours: This intervention is within the nurse’s scope of practice and does not require a physician’s order. It is an independent action that helps prevent complications like pressure ulcers.
C. Starting IV antibiotics: This action requires a physician's order and is a dependent nursing intervention.
D. Administering medication for pain: Administering medication requires a physician’s order and is not considered an independent nursing action.

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The client has been admitted and placed on fall precautions. The nurse explains to the patient that interventions for the precautions include: (Select All that Apply)

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Naxlex Comprehensive Predictor Exams

Correct Answer is D

Explanation

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Correct Answer is B

Explanation

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