A night shift nurse works and cares for several clients at risk for falls.
Which of the following actions should the nurse take?
Instruct the clients to use the call light.
Keep the clients' rooms dark.
Move overbed tables away from the bed.
Perform client checks every 4 hours.
The Correct Answer is A
The correct answer is A. Instruct the clients to use the call light.
Choice A rationale:
Instructing clients to use the call light ensures they can request assistance before getting up, which is a key strategy in preventing falls, especially during the night when visibility is reduced and the risk of disorientation is higher.
Choice B rationale:
Keeping the clients' rooms dark can increase the risk of falls as it makes it difficult for clients to see obstacles and navigate their environment safely. Adequate lighting is important for fall prevention.
Choice C rationale:
Moving overbed tables away from the bed can actually make it harder for clients to reach essential items and might increase the risk of falls if clients have to stretch or lean awkwardly to get what they need. The overbed table should be positioned within easy reach.
Choice D rationale:
Performing client checks every 4 hours is not frequent enough to effectively monitor at-risk clients. More frequent checks, such as hourly, are recommended to ensure safety and promptly address any needs that could prevent a fall.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale:
Healthcare-associated infections (HAIs) do not necessarily occur due to compromised immunity. HAIs refer to infections that patients acquire while receiving treatment for medical or surgical conditions, and they can happen to individuals with varying levels of immunity.
Choice B rationale:
While infections during therapeutic procedures are a concern, not all healthcare-associated infections occur during such procedures. HAIs can happen in various healthcare settings and not limited to therapeutic procedures.
Choice C rationale:
Inhaling pathogens in a healthcare setting might lead to infections, but not all healthcare-associated infections happen due to inhalation. HAIs can occur through different modes of transmission.
Choice D rationale:
Healthcare-associated infections (HAIs) occur when a patient acquires an infection while receiving care in a healthcare setting, including hospitals. This can involve various sources, such as contaminated medical equipment, surgical procedures, or interactions with healthcare personnel.
Correct Answer is D
Explanation
Choice A rationale:
Checking a restrained patient every 45 minutes might be too frequent and could interfere with the patient's rest and comfort, especially if the restraint is necessary for their safety. It could also lead to increased agitation and resistance from the patient, making it more challenging for the healthcare providers to manage the situation effectively.
Choice B rationale:
Checking on a restrained patient every 30 minutes is also too frequent for the reasons mentioned above. Patients need some time to rest and recover, and constant monitoring might be perceived as intrusive and threatening, potentially escalating the situation.
Choice C rationale:
Checking on a restrained patient every hour might not be sufficient, especially if the patient is at high risk of harming themselves or others. Waiting for an hour between checks could lead to dangerous situations, as a lot can happen in that time frame.
Choice D rationale:
Checking on a restrained patient every 2 hours strikes a balance between ensuring the patient's safety and respecting their privacy and comfort. It allows healthcare providers to monitor the patient's condition and intervene promptly if necessary while also giving the patient some space to rest and recover.
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