The student nurse has identified that the patient is a risk for falling and has implemented fall precautions. What action taken by the student would require further teaching from the clinical faculty?

Applies non skid socks before getting the patient out of bed.

Activates the chair alarm when the patient is sitting in the chair.

Ensures that the bed is in the lowest position prior to leaving the room.

Places the patient on bedrest.

Answer and Explanation

The Correct Answer is D

A. Applies non-skid socks before getting the patient out of bed: Non-skid socks help prevent slipping and are an appropriate fall precaution.

B. Activates the chair alarm when the patient is sitting in the chair: Chair alarms alert staff if the patient attempts to get up unassisted, reducing fall risk.

C. Ensures that the bed is in the lowest position prior to leaving the room: Keeping the bed low reduces the severity of injury in case of a fall.

D. Places the patient on bed rest: Bed rest is not a standard fall precaution unless medically necessary. It can lead to deconditioning and further weakness, increasing fall risk.

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Correct Answer is D

Explanation

A. "Void every four hours even if you feel like you do not need to urinate." While frequent voiding is beneficial, forcing a rigid schedule is not necessary. The priority is voiding after intercourse and staying hydrated to flush bacteria.

B. "You should perform Kegel exercises several times a day." Kegel exercises strengthen the pelvic floor but do not prevent UTIs.

C. "When possible, you should try to take a tub bath instead of a shower." Soaking in a bath can introduce bacteria into the urethra, increasing UTI risk. Showers are recommended.

D. “It is important to clean front to back during bathing and after using the restroom.” Wiping front to back prevents the spread of bacteria from the perineal area to the urethra, a major cause of UTIs.

A. Avoid using your fingers to open the mouth. B. Apply moisturizer to the oral mucosa and lips. C. Brush the teeth with a soft bristled toothbrush D. Use a toothbrush with a suction attachment

Correct Answer is D

Explanation

A. Avoid using your fingers to open the mouth: While this is a safety measure to prevent injury, it is not the most important intervention.

B. Apply moisturizer to the oral mucosa and lips: While this is beneficial for comfort, preventing aspiration and maintaining airway patency are higher priorities.

C. Brush the teeth with a soft-bristled toothbrush: Oral hygiene is important, but the highest priority is preventing aspiration.

D. Use a toothbrush with a suction attachment: Suction prevents the accumulation of oral secretions, reducing the risk of aspiration pneumonia in a sedated patient.

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Laboratory Test	Reference Range	Patient Results
White Blood Cells	5,000- 10,000/mm3	9,500/mm3
Neutrophil Count	2.500-8,000/mm3	5,200/mm3
HIV	Negative	Positive

The student nurse has identified that the patient is a risk for falling and has implemented fall precautions. What action taken by the student would require further teaching from the clinical faculty?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is D

Explanation

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Correct Answer is D

Explanation

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