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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Use soap and water to clean the client's perineum: Correct. Using soap and water is the standard method for cleaning the perineum to ensure it is effectively cleaned while maintaining hygiene.
B. Use the same section of washcloth for each area cleaned: Incorrect. To prevent cross-contamination, the nurse should use a clean section of the washcloth or a new washcloth for each area cleaned.
C. Allow the client's perineum to air dry: Incorrect. The perineum should be gently patted dry with a clean towel to prevent irritation and ensure proper drying.
D. Start at the client's rectum and clean to the client's perineum: Incorrect. The proper technique is to clean from the perineum to the rectum to prevent the spread of bacteria from the rectal area to the vaginal area.
Correct Answer is C
Explanation
A. Grandparents: While grandparents can provide valuable information, parents are typically the primary source of information about a child’s medical history, current symptoms, and behavioral changes.
B. Admitting provider: The admitting provider's role is to assess and diagnose the client. While they provide essential clinical information, they are not the primary source for personal and historical data about the client.
C. Parents: Parents are the most reliable source of information regarding the toddler's medical history, current condition, and any changes in behavior or health. They are most familiar with the child’s day-to-day health and medical background.
D. Medical record: Although the medical record contains important information, it may not have the most recent updates or contextual details that parents can provide. It is important to corroborate the information in the medical record with input from the parents.
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