A nurse is admitting a client who is at risk for falls to a medical-surgical unit. Which of the following actions should the nurse take?

Place the bedside table 0.9 m (3 feet) away from the bed.

Provide the client with a night light.

Elevate full-length side rails on both sides of the client's bed.

Keep the client's room temperature at 18° C (64.4° F).

Answer and Explanation

The Correct Answer is B

A. Place the bedside table 0.9 m (3 feet) away from the bed:

While having a bedside table nearby can be convenient for clients to access essential items, the specific distance of 0.9 m (3 feet) is not a standard guideline for falls prevention. Placing the bedside table closer to the bed may actually improve accessibility for the client, but it's not the most crucial action for falls prevention in this scenario.

B. Provide the client with a night light.

Falls prevention strategies aim to create a safe environment for clients at risk of falling. Providing a night light helps improve visibility during nighttime, reducing the risk of falls due to poor lighting. It assists clients in navigating their surroundings safely, especially when getting out of bed during the night.

C. Elevate full-length side rails on both sides of the client's bed:

Using full-length side rails on the bed can increase the risk of entrapment and injury, especially for clients at risk of falls. Current evidence suggests that the use of physical restraints, such as full-length side rails, does not effectively prevent falls and may contribute to adverse outcomes.

D. Keep the client's room temperature at 18°C (64.4°F):

While maintaining a comfortable room temperature is important for client comfort, the specific temperature of 18°C (64.4°F) is not a standard guideline for falls prevention. Instead, ensuring a comfortable temperature range based on individual client preferences and environmental factors is appropriate.

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Free Nursing Study Resources

Correct Answer is A

Explanation

A. "Walk for 30 minutes three to five times each week."

Regular weight-bearing exercises, such as walking, are beneficial for maintaining bone density and reducing the risk of osteoporosis. Walking for 30 minutes three to five times per week can help strengthen bones, improve balance, and reduce the risk of fractures associated with osteoporosis.

B. "Perform water aerobics three times each week": While water aerobics is a beneficial form of exercise for overall health and fitness, it may not be as effective as weight-bearing exercises like walking for preventing osteoporosis. Water-based activities do not provide the same impact on bone density as weight-bearing exercises.

C. "Maintain a lean body mass": While maintaining a healthy body weight is important for overall health, particularly for reducing the risk of conditions like heart disease and diabetes, it may not specifically prevent osteoporosis. In fact, having a low body weight or being underweight can increase the risk of osteoporosis.

D. "Increase intake of vitamin B12": Vitamin B12 is important for various bodily functions, including nerve function and the formation of red blood cells, but it is not directly linked to the prevention of osteoporosis. Adequate calcium and vitamin D intake, along with weight-bearing exercise, are key factors in preventing osteoporosis.

A. Ask the family if they wish to assist in washing the client's body. B. Remove the client's dentures for their family to keep. C. Leave the client's eyes open until the family views the body. D. Turn overhead lights to a bright setting.

Correct Answer is A

Explanation

A. Asking the family if they wish to assist in washing the client's body:

This is an important first step because it respects the family's cultural or religious practices and allows them to participate in the care of their loved one if they choose. It sets the tone for sensitive and respectful postmortem care.

B. Removing the client's dentures for their family to keep:

Dentures are usually leftin the mouth tomaintain facial shape.However, this action is not the first priority.

C. Leaving the client's eyes open until the family views the body:

It is generally recommended to gently close the client's eyes after death as part of the postmortem care process. Leaving the eyes open might be distressing for the family, so this action should not be performed first.

D. Turn overhead lights to a bright setting.

Bright lighting may not be comforting for the family or create a peaceful environment. Dim or soft lighting is usually preferred to create a calming atmosphere during this sensitive time. Therefore, this is not the first action the nurse should take.

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