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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A: Increased Ca+ influx with sympathetic stimulation that raises the heart rate is a manifestation of sympathetic innervation. Sympathetic activation leads to the release of norepinephrine, which enhances the influx of calcium ions (Ca+) into cardiac muscle cells, resulting in increased contractility and heart rate.
Choice B: Sympathetic activation does increase the inotropic effect (contractility) of the heart, but it is primarily mediated by the increased influx of calcium ions (Ca+).
Choice C: Sympathetic activation does not decrease dromotrophy (conduction speed). Instead, it can increase the conduction speed through the cardiac conduction system.
Choice D: Increased Na+ influx with sympathetic stimulation does not reduce pacemaker firing; instead, it contributes to the enhanced excitability and automaticity of cardiac cells.
Correct Answer is A
Explanation
Choice A: A practical nurse assisting the healthcare provider with a lumbar puncture at the bedside is a high-risk procedure that requires direct supervision by an RN or a qualified healthcare provider. The RN should ensure the procedure is performed safely and effectively, as it involves potential risks and complications.
Choice B: Starting a transfusion of packed red blood cells is an important nursing intervention, but it does not necessarily require direct supervision by an RN, especially if the nurse has been trained and is competent in administering blood transfusions.
Choice C: Weighing an obese bedfast client using a bed scale is a routine nursing task that can be performed by unlicensed assistive personnel (UAP) with appropriate training. While the RN should ensure that the UAP is properly trained, direct supervision may not be required for this specific task.
Choice D: Accessing a client's implanted port to start an infusion of Ringer's Lactate is a nursing task that can be performed by a graduate nurse, especially if they have received appropriate training and competency validation. Direct supervision by an RN may not be necessary in this situation.
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