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. Weighing once weekly might not be frequent enough for monitoring changes related to heart failure or medication effects.
B. The timing of hydrochlorothiazide administration isn't critical to safety considerations; it's typically taken in the morning due to its diuretic effect.
C. Leaving a light on in the bathroom at night can help prevent falls, a common concern in older adults, especially those with heart failure.
D. Taking a hot bath before bed might not contribute significantly to safety considerations related to heart failure or medication use.

A. Rub the peristomal skin dry after cleaning. B. Change the pouch once every 24 hr. C. Ensure the pouch is 0.32 cm (1/8 in) larger than the stoma. D. Apply the pouch while the skin barrier is still damp.

Correct Answer is C

Explanation

A. Rather than rubbing dry, patting the peristomal skin dry after cleaning is recommended.
B. The frequency of changing the pouch depends on various factors, not a fixed 24-hour schedule.
C. Ensuring the pouch is slightly larger than the stoma prevents irritation and damage.
D. Applying the pouch when the skin barrier is dry ensures better adhesion.

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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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