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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","B","C"]
Explanation
These actions ensure the safety of the client by reducing the risk of falls, confusion and injury.
Keeping a call bell within the client’s reach allows them to ask for help when needed.
Keeping a dim light on at night helps them orient themselves and see their surroundings.
Keeping unnecessary furniture out of the way prevents tripping and cluttering. Choice D is wrong because keeping all side rails up at all times can be considered a form of physical restraint, which is associated with many professional, legal and ethical challenges. Physical restraint should only be used as a last resort when other alternatives have failed or are not feasible. Keeping all side rails up can also increase the risk of injury if the client tries to climb over them.
Choice E is wrong because keeping all lights off at night can increase the risk of falls and confusion for the client.
Older adults may have impaired vision and cognition, and they may need to use the bathroom frequently at night. Keeping all lights off can make it difficult for them to find their way and increase their anxiety.
Correct Answer is A
Explanation
This is because people with COPD are more likely to catch respiratory infections such as colds, flu and pneumonia, which can worsen their symptoms and cause further lung damage. An influenza vaccine can help prevent flu and reduce the risk of complications.
Choice B. A broad-spectrum antibiotic is wrong because antibiotics are only effective against bacterial infections, not viral ones. Antibiotics are usually prescribed for COPD exacerbations caused by bacterial infections, but not for prevention.
Choice C. A bronchodilator is wrong because bronchodilators are medications that relax the muscles around the airways and make breathing easier. They are used to treat the symptoms of COPD, but they do not prevent respiratory infections.
Choice D. A corticosteroid is wrong because corticosteroids are anti inflammatory drugs that reduce swelling and mucus production in the airways. They are also used to treat the symptoms of COPD, but they do not prevent respiratory infections. In fact, long-term use of corticosteroids may increase the risk of infections by suppressing the immune system.
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