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?

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

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

Provide the client with a night light.

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

Answer and Explanation

The Correct Answer is C

A. Elevating full-length side rails on both sides of the client's bed is not recommended, as it can increase the risk of injury if the client tries to climb over them or gets trapped between them.

B. Placing the bedside table 0.9 m away is unrelated to fall prevention.
C. A night light can help the client see better in the dark and avoid tripping or falling over objects.
D. Maintaining the room temperature is important for comfort but doesn't directly prevent falls.

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Correct Answer is C

Explanation

A. Moving joints to the point of mild pain can cause discomfort or injury and isn't advisable during passive range-of-motion exercises.
B. Moving joints quickly might increase the risk of injury or discomfort and isn't typically recommended for passive range-of-motion exercises.
C. Repeating movements 3 to 5 times is a standard recommendation for passive range-of-motion exercises to improve joint flexibility and prevent stiffness.
D. Performing these movements once a day might not yield optimal benefits for joint mobility in clients with decreased mobility.

A. Obtain a random blood glucose daily. B. Change the PN infusion bag every 48 hr. C. Prepare the client for a central venous line. D. Administer the PN and fat emulsion separately.

Correct Answer is C

Explanation

A. Obtaining a random blood glucose daily is important for monitoring glucose levels but might not be specifically related to the introduction of PN in this context.
B. Changing the PN infusion bag every 48 hours might not be universally applicable; the frequency of changing PN bags depends on institutional policies and the stability of the solution being administered.
C. PN with high concentrations of dextrose and fat emulsions typically requires a central venous line for administration to prevent peripheral vein irritation or damage.
D. Administering PN and fat emulsion separately might not be practical as PN usually includes all necessary components in a single infusion.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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