The nurse is planning a fall prevention program for the residents at a long-term care facility. Which intervention is most important in providing a safe environment?

Apply a vest restraint prophylactically to confused residents.

Accompany residents older than 80 years during ambulation.

Encourage clients to wear rubber-soled shoes.

Leave the hall lights on during the night.

Answer and Explanation

The Correct Answer is C

Choice A: Applying restraints should not be the first approach in fall prevention and is associated with risks and ethical considerations.

Choice B: Accompanying residents during ambulation is a helpful practice but may not be feasible at all times. It's essential to promote independence when possible.

Choice C: Encouraging clients to wear rubber-soled shoes is an important fall prevention measure, as it can provide better traction and stability when walking.

Choice D: Leaving the hall lights on during the night may be helpful, but it is not the most critical intervention for fall prevention. Proper footwear and other measures should take precedence.

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Correct Answer is A

Explanation

Choice A: The client's statement reflects an understanding of the DASH diet's emphasis on lean meats, nuts, and dried beans as protein sources, which aligns with the principles of the diet.

Choice B: The DASH diet encourages the consumption of more than 4 to 6 servings of fruits and vegetables daily.

Choice C: The DASH diet does not eliminate dairy-based products but recommends choosing low-fat or fat-free options.

Choice D: The DASH diet does not focus on gluten-free foods but rather on overall dietary patterns that promote heart-healthy eating.

A. Check mental acuity. B. Measure urinary output. C. Inspect for sacral edema. D. Auscultate all lung fields.

Correct Answer is D

Explanation

Choice A: Checking mental acuity is important for assessing the client's cognitive function, but it may not be the most crucial intervention in the context of left- sided heart failure.

Choice B: Measuring urinary output is a valuable assessment in clients with heart failure, but it is not the most important intervention among the choices provided.

Choice C: Inspecting for sacral edema is a relevant assessment for clients with heart failure, especially when assessing for fluid retention. However, it may not be the highest priority in this case.

Choice D: Auscultating all lung fields is the most important intervention for a client with left-sided heart failure. Left-sided heart failure often results in pulmonary congestion, and auscultating the lung fields can provide critical information about the presence of crackles, wheezes, or other abnormal breath sounds, indicating worsening heart failure.

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The nurse is planning a fall prevention program for the residents at a long-term care facility. Which intervention is most important in providing a safe environment?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is reviewing a nutrition plan with a client newly diagnosed with hypertension. Which statement by the client indicates an understanding of the Dietary Approaches to Stop Hypertension (DASH) diet?

Correct Answer is A

Explanation

The practical nurse (PN) is assessing an older client with left-sided heart failure (HF). What intervention is most important for the PN to implement?

Correct Answer is D

Explanation

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