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 A

Explanation

A. In emergency situations where the client is unconscious and requires immediate life-saving surgery, implied consent is assumed. The nurse should prepare the client for surgery without waiting for family members or a formal consent process. Delaying treatment could jeopardize the client's life.

B. Contacting the ethics committee could delay the urgent care needed in an emergency situation. Immediate action should be taken in the best interest of the client.

C. Waiting for a family member to arrive could delay critical care, which may lead to worsening of the client's condition or even death.

D. The surgeon does not need to provide consent. It is the healthcare team's responsibility to act in the client's best interest when the client is unable to provide consent in an emergency.

A. Loosen the client's bed linens. B. Massage the client's sacrum. C. Provide bright lights in the client's room. D. Offer to play music in the client's room.

Correct Answer is D

Explanation

A. Loosening the bed linensmay not have a significant effect on the client's pain level, and may increase the risk of infection or further injury to the pressure ulcer.
B. Massaging the sacrum in the context of a pressure injury might exacerbate the condition and isn't recommended.
C. Providing bright lights might not specifically address the acute pain from the pressure injury.
D. Music therapy is a nonpharmacological intervention that can help reduce pain perception, anxiety, and stress in clients who have acute pain. Music can also provide distraction, relaxation, and comfort to the client.

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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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Naxlex Comprehensive Predictor Exams

A nurse in an emergency department is caring for a client who is unconscious and requires surgery. There is no one available to give consent for the treatment. Which of the following actions should the nurse take?

Correct Answer is A

Explanation

A nurse is planning care for a client who has acute pain as a result of a pressure injury to the sacrum. Which of the following nonpharmacological interventions should the nurse include in the plan?

Correct Answer is D

Explanation

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