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).
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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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Administer the client's insulin dose using a tuberculin syringe:
While using an appropriate syringe for insulin administration is important, ensuring the accuracy of the dosage precedes the actual administration. Therefore, verifying the dose takes precedence over selecting the syringe.
B. Use a filter needle when withdrawing medication from the multidose vial:
While using a filter needle can be beneficial to prevent contamination, ensuring the correct dosage is more critical in preventing adverse effects associated with incorrect insulin administration.
C. Verify the dose of insulin with another nurse once it is prepared.
Before administering insulin to a client with type 1 diabetes, it is essential to ensure accuracy in dosage. Verifying the dose with another nurse helps minimize the risk of errors, ensuring the client receives the correct amount of insulin. This step aligns with the principle of double-checking medications for safety, especially in critical situations like insulin administration.
D. Mix the client's long-acting and rapid-acting insulin dose in one syringe:
Mixing different types of insulin in one syringe is not standard practice unless specifically instructed by a healthcare provider. This step should be performed only if explicitly ordered an
Correct Answer is B
Explanation
Correct answer: B
A. "The food is not great, but it is nice not having to do all of my own cooking.":
This statement acknowledges a minor issue with the food but overall expresses satisfaction with the convenience of not having to cook, indicating some level of acceptance of the transition.
B. "I don't want to go to the activity room because none of the other residents can hear."
This statement suggests a feeling of disconnection or dissatisfaction with the activities available in the assisted living facility. The client may be expressing frustration or a sense of isolation because the other residents cannot hear, which could hinder their ability to engage socially and participate in activities. Difficulty accepting the transition may manifest as resistance or reluctance to participate in aspects of facility life, such as group activities, due to perceived limitations or barriers.
C. "The staff sometimes have to remind me to use a cane when I walk in the hall.":
While this statement may indicate some adjustment to the need for assistance or reminders, it does not necessarily suggest difficulty accepting the transition. Instead, it reflects a willingness to comply with safety recommendations provided by the staff.
D. "When I go out, I've been using public transportation since I can't drive anymore":
This statement acknowledges a change in transportation habits due to inability to drive, which may be a practical adaptation to the client's circumstances rather than a sign of difficulty accepting the transition to assisted living.
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