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 ["B","C","E"]

Explanation

A. At the end of the shift is incorrect. Medication verification is done before administration, not at the end of the shift.

B. When removing the medication from the medication drawer is correct. This is the first check to ensure the correct medication is selected.

C. Directly before administering the medication is correct. This is the final check to verify that the correct medication, dose, route, and time match the prescription before giving it to the client.

D. When reconciling counts of controlled substances is incorrect. While controlled substances require counting and verification, this is separate from the three medication checks performed during administration.

E. When preparing the medication dosage is correct. This is the second check, ensuring that the correct medication and dose are prepared accurately before administration.

A. Turn the client onto their side. B. Help the client lie on the floor. C. Loosen the client's clothing. D. Move items in the room away from the client.

Correct Answer is B

Explanation

A. Turning the client onto their side helps prevent aspiration and ensures a clear airway but since the client is seated on a chair, they run the risk of getting a fall hence lying them down is the priority.
B. If a client has a seizure when seated, it is best to ensure their safety by lying them on the floor and moving any objects that can cuase injury.
C. Loosening clothing is important but not the priority over ensuring a clear airway.
D. Moving items away from the client is important to prevent injury, but ensuring airway safety comes first.

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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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