The RN performs an admission assessment and determines the client is a fall risk. What is a priority nursing intervention for this client?
Provide a walker.
Place a chair on either side of the bed.
Provide a cane.
Place a fall risk wrist band on the client.
The Correct Answer is D
This is because a fall risk wristband alerts the staff and other caregivers that the client is at risk of falling and needs extra precautions and supervision. A walker, a cane, or a chair on either side of the bed are not priority interventions for a fall risk client, as they do not address the root cause of the problem or prevent potential falls.
Choice A is wrong because a walker may not be appropriate for the client’s condition or mobility level, and it may pose a tripping hazard if not used correctly.
Choice B is wrong because placing a chair on either side of the bed may limit the client’s access to the bed or the bathroom, and it may also create clutter and obstruction in the room.
Choice C is wrong because a cane may not provide enough stability or support for the client, and it may also be difficult to use in narrow spaces or on slippery surfaces.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
The client may have a ruptured appendix, which is a life-threatening complication of appendicitis. A ruptured appendix can cause peritonitis, which is an infection of the lining of the abdomen, or an abscess, which is a collection of pus around the appendix. These conditions require immediate medical attention and surgery to remove the appendix and clean the abdominal cavity.
Choice A is wrong because administering the prescribed medication may mask the symptoms of a ruptured appendix and delay diagnosis and treatment.
Choice B is wrong because repositioning the client and applying a heating pad may increase the risk of rupture or spread of infection.
Choice D is wrong because calling the operating room team is not the nurse’s responsibility and may not be feasible depending on the availability of the surgical team and the operating room.
Correct Answer is A
Explanation
Watching television until falling asleep at night is a poor sleep habit because it can interfere with the body’s natural sleep-wake cycle and make it harder to fall asleep and stay asleep. Television can also expose the eyes to bright light and stimulating or stressful content, which can affect the production of melatonin, a hormone that regulates sleep.
Choice B is wrong because having a small snack and taking a bath before going to bed each day are good sleep habits that can promote relaxation and sleep quality.
Choice C is wrong because not taking naps throughout the day is a good sleep habit that can help maintain a consistent sleep schedule and avoid disrupting the night-time sleep.
Choice D is wrong because going to bed and getting up at the same times each day is a good sleep habit that can reinforce the body’s circadian rhythm and make it easier to fall asleep and wake up.
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