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
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.
Correct Answer is B
Explanation
The nurse has a legal and ethical obligation to report any suspected abuse of a vulnerable client, such as an older adult. Reporting the findings is the first action the nurse should take to protect the client and initiate an investigation by the appropriate authorities.
Choice A is wrong because investigating further to confirm the suspicion is not within the nurse’s scope of practice and could delay the reporting process.
Choice C is wrong because providing the client with a crisis hotline number is not enough to ensure the client’s safety and well-being.
The client might not be able to access the hotline or might be afraid to use it.
Choice D is wrong because discussing respite care with the client’s family is not appropriate at this stage.
The nurse should not assume that the family member is willing or able to provide adequate care for the client.
Respite care might be an option after the abuse is reported and investigated.
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