What interventions should the nurse include in the plan of care for a patient on fall precautions? Select all that apply.

Restrain the patient with a chemical sedative.

Encourage the patient to use grab bars located near toilets and showers.

Place the call light within the patient's reach.

Conduct rounds every four hours.

Apply brakes on wheelchairs and bed.

Answer and Explanation

Correct Answer : B,C,E

Choice A rationale:

Restrain the patient with a chemical sedative. Rationale: Restraints, especially chemical sedatives, should be avoided whenever possible due to the risk of complications and patient distress. Restraints can lead to decreased mobility, increased agitation, and other adverse effects. They should only be used as a last resort and with appropriate justification, such as ensuring patient or staff safety in emergency situations.

Choice B rationale:

Encourage the patient to use grab bars located near toilets and showers. Rationale: Installing grab bars in bathrooms helps prevent falls by providing support and stability for patients, especially those with mobility issues. Encouraging their use promotes patient independence and safety while performing essential activities of daily living.

Choice C rationale:

Place the call light within the patient's reach. Rationale: Placing the call light within the patient's reach ensures that the patient can easily summon assistance when needed. Prompt response to patient requests can prevent accidents and falls by addressing the patient's needs in a timely manner.

Choice D rationale:

Conduct rounds every four hours. Rationale: Conducting regular rounds allows healthcare providers to assess the patient's condition, address their needs, and identify potential fall risks. However, the specific frequency of rounds may vary based on the patient's condition and the healthcare facility's policies. Some patients may require more frequent monitoring, especially if they are at a higher risk of falling.

Choice E rationale:

Apply brakes on wheelchairs and beds. Rationale: Applying brakes on wheelchairs and beds prevents unintended movement, enhancing patient safety and reducing the risk of falls. It ensures that the patient's mobility aids remain stationary, providing stability when the patient is transferring or repositioning.

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Correct Answer is C

Explanation

Choice A rationale:

Ethical dilemma involves a situation in which a person is faced with conflicting moral principles, making it difficult to choose the right course of action. In this scenario, the nurse is not dealing with conflicting moral principles but rather providing information about end-of-life care options, demonstrating respect for the patient's autonomy.

Choice B rationale:

Nonmaleficence is the principle of doing no harm. While it is an important ethical principle in nursing, it does not directly apply to the situation described. The nurse is not making decisions that could harm the patient but is instead providing information and support regarding end-of-life care options.

Choice C rationale:

Autonomy refers to the right of individuals to make their own decisions about their own lives and bodies, even if those decisions are not in their best interest according to others. In this scenario, the nurse is respecting the patient's autonomy by providing information and discussing various care options, allowing the patient to make informed decisions about their end-of-life care.

Choice D rationale:

Social justice involves promoting fairness and equity in the distribution of resources and opportunities. While social justice is an important nursing value, it does not directly apply to the situation described. The nurse is primarily focused on respecting the patient's autonomy and providing information about end-of-life care options.

A. Carbon dioxide levels are higher in the alveoli during inhalation. B. Alveoli collapse during the inhalation cycle. C. Oxygen moves from the alveoli to the capillaries. D. Exhaling carbon dioxide requires effort.

Correct Answer is C

Explanation

Choice A rationale:

During inhalation, carbon dioxide levels are lower in the alveoli due to the exchange of gases. The higher concentration of carbon dioxide is found in the blood, which diffuses into the alveoli for elimination during exhalation.

Choice B rationale:

Alveoli do not collapse during the inhalation cycle. Surfactant, a substance produced by type II alveolar cells, reduces surface tension and prevents alveoli from collapsing, ensuring efficient gas exchange.

Choice C rationale:

Oxygen moves from the alveoli to the capillaries, while carbon dioxide moves from the capillaries to the alveoli. This exchange of gases occurs due to differences in partial pressures, facilitating the uptake of oxygen by red blood cells and the removal of carbon dioxide from the body.

Choice D rationale:

Exhaling carbon dioxide is a passive process that does not require significant effort. The respiratory muscles relax during exhalation, allowing the lungs to passively expel carbon dioxide from the body as a waste product of metabolism.

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What interventions should the nurse include in the plan of care for a patient on fall precautions? Select all that apply.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a terminally ill patient with questions regarding end-of-life care options.The nurse provides an informational packet to the patient, and discusses the various care options available.The nurse is demonstrating which professional value?

Correct Answer is C

Explanation

Which statement regarding the anatomy and physiology of the respiratory system is correct?

Correct Answer is C

Explanation

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What interventions should the nurse include in the plan of care for a patient on fall precautions? Select all that apply.