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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Correct Answer is B

Explanation

A. The client adjusts the head of their bed to 90°: Adjusting the head of the bed to 90° is a correct action for clients with dysphagia as it helps facilitate swallowing by promoting an upright position, reducing the risk of aspiration.

B. The client drinks their thickened juice with a straw.

Drinking thickened liquids with a straw is not recommended for clients with dysphagia. Straws can increase the risk of aspiration, as they bypass the natural protection mechanisms in the mouth and throat that help prevent liquids from entering the airway. Therefore, the nurse should intervene and provide the client with an appropriate drinking cup instead of a straw when consuming thickened liquids.

C. The client tucks their chin when they swallow: Tucking the chin when swallowing is a recommended technique for clients with dysphagia, as it helps close off the airway and directs the food or liquid toward the esophagus, reducing the risk of aspiration.

D. The client takes frequent breaks while eating: Taking frequent breaks while eating is a beneficial strategy for clients with dysphagia, as it allows them to rest and swallow safely without feeling rushed or overwhelmed by large amounts of food or liquid.

A. Grab bars are installed in the shower. B. The hot water heater is set to 47° C (117° F). C. There is an area rug covering a tile floor. D. Prescriptions are stored in a medication organizer.

Correct Answer is C

Explanation

A. Grab bars are installed in the shower: Installing grab bars in the shower is a safety measure that helps prevent falls and assists the client in safely maneuvering in the bathroom. This finding indicates a safe environment and does not require intervention.

B. The hot water heater is set to 47°C (117°F): The hot water heater set at 47°C (117°F) poses a scalding risk, especially for older adults with decreased sensation or mobility issues. The recommended safe temperature for hot water heaters is typically below 49°C (120°F) to prevent burns. Therefore, the nurse should intervene to adjust the temperature to a safer level.

C. There is an area rug covering a tile floor.

Area rugs covering tile floors can pose a significant fall risk, especially for older adults with osteoporosis, who are more susceptible to fractures. The rug can slip or bunch up, leading to trips and falls. Therefore, the nurse should intervene to remove the area rug or secure it firmly to the floor to prevent accidents.

D. Prescriptions are stored in a medication organizer: Storing prescriptions in a medication organizer promotes medication adherence and organization, which is beneficial for older adults managing multiple medications. This finding indicates good medication management and does not require intervention.

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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?

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