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 ["A","D","E","F"]

Explanation

A. The client will teach back information about safe crutch walking on day 1: This goal includes a specific time frame ("on day 1") which makes it a timed component. It establishes when the client is expected to demonstrate understanding, aligning with the SMART criteria for setting time-specific goals.

B. The client will demonstrate safe crutch walking: While this goal describes a desired outcome, it does not include a time frame, so it lacks the timing component needed for SMART criteria.

C. The client will not lean on the crutches to support their body weight: This goal focuses on the behavior change but does not specify when this should be achieved, missing the timed element of SMART goals.

D. The client will ambulate 5 feet in one day: This goal has a specific time frame ("in one day"), indicating when the client should achieve the goal, which is a critical aspect of SMART outcomes.

E. The client will walk 10 feet by day 2: This goal includes a specific time frame ("by day 2"), providing a clear deadline for achieving the goal, which is essential for SMART objectives.

F. The client will walk 20 feet by day 3: This goal includes a specific time frame ("by day 3"), which provides a deadline for reaching the goal, meeting the criteria for SMART goals.

G. The client will explain 4 principles of crutch safety: This goal describes an outcome but does not include a time frame, so it lacks the timed aspect necessary for SMART goals.

H. The client will explain how to keep crutches in safe condition: This goal focuses on an outcome without specifying a deadline, thus missing the timed component required for SMART goal setting.

A. Clean hands with soap and water after caring for the client B. Place the client in a room with negative pressure airflow C. Wash hands for 10 seconds after caring for the client D. Apply a mask on the client when they are outside their room

Correct Answer is A

Explanation

A. Clean hands with soap and water after caring for the client: C. difficile spores are resistant to alcohol-based hand sanitizers. Therefore, it is essential to use soap and water to effectively remove the spores from hands.
B. Place the client in a room with negative pressure airflow: C. difficile is not an airborne infection, so negative pressure airflow is not required. This measure is typically used for infections such as tuberculosis.
C. Wash hands for 10 seconds after caring for the client: Handwashing with soap and water should be done for at least 20 seconds to effectively remove C. difficile spores.
D. Apply a mask on the client when they are outside their room: A mask is not necessary for clients with C. difficile, as the infection is not transmitted through respiratory droplets but rather through fecal-oral transmission.

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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)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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

Explanation

nurse is caring for a client who has Clostridium difficile (C. difficile). Which of the following actions should the nurse take?

Correct Answer is A

Explanation

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