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.

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

Provide the client with a night light.

Answer and Explanation

The Correct Answer is D

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

While side rails are used to prevent falls, full-length side rails can pose a risk to the client. They may give a false sense of security, and there's a risk of entrapment or injury if the client tries to climb over them. The use of side rails requires careful assessment and consideration of the individual client's needs.

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

Placing the bedside table 0.9 m (3 feet) away from the bed may not directly address the risk of falls. The focus should be on making essential items easily accessible to the client to minimize the need for them to get out of bed, especially during the night. Placing items within the client's reach is a more practical approach.

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

While maintaining a comfortable room temperature is important for the client's overall well-being, it is not a direct preventive measure for falls. Falls are more likely to be prevented by addressing environmental factors, ensuring clear pathways, and providing adequate lighting.

D. Provide the client with a night light:

This is the appropriate action. A night light helps improve visibility during nighttime, reducing the risk of falls. It allows the client to see their surroundings better and navigate the room safely if they need to get out of bed.

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Correct Answer is D

Explanation

A. Combining medications with the formula in the feeding bag:

This is not recommended because it may lead to interactions between the medications and the enteral feeding formula. Medications may also adhere to the tubing or interfere with the absorption of nutrients from the feeding formula.

B. Diluting each crushed medication with warm water:

While diluting medications may be necessary for some drugs, it is not a general rule for all medications. Additionally, dilution with warm water may not be appropriate for all drugs, and the amount of water needed may vary. It's safer to use a standardized method, such as flushing the tube with sterile water.

C. Mixing the medications together in a single syringe:

This is generally not recommended because different medications may have incompatible properties or form precipitates when mixed together. Mixing medications in a single syringe can compromise the effectiveness of each medication and may lead to unpredictable reactions.

D. Flush the NG tube with 5 mL of sterile water for irrigation prior to administration:

Flushing the tube with sterile water helps ensure that the tube is clear of any residual formula, preventing potential interactions between the medication and the enteral feeding. It also helps clear the tube, reducing the risk of clogs or blockages. Using sterile water helps maintain aseptic technique.

A. Cholestrol level B. Prealbumin level C. History of malnutrition D. History of diabetes mellitus E. History of hyperlipidemia)

Correct Answer is ["B","C","D"]

Explanation

A. Cholesterol level:

While hyperlipidemia (elevated cholesterol levels) is associated with cardiovascular disease, it is not a direct factor affecting wound healing. Cholesterol levels primarily impact vascular health and are not directly related to the cellular and tissue processes involved in wound repair.

B. Prealbumin level:

Prealbumin is a protein that reflects recent dietary intake and nutritional status. Low prealbumin levels can indicate malnutrition, which is associated with delayed wound healing. Adequate protein intake is crucial for tissue repair and wound healing.

C. History of malnutrition:

Malnutrition is a significant risk factor for delayed wound healing. Adequate nutrition is essential for the body to carry out the processes involved in wound healing, including cell proliferation, collagen synthesis, and immune function.

D. History of diabetes mellitus:

Diabetes mellitus can impair wound healing due to factors such as reduced blood flow, impaired immune response, and neuropathy. Elevated blood sugar levels in diabetes can interfere with the normal healing processes, leading to delayed wound healing.

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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

A nurse is preparing to administer several medications via an NG tube to a client who is receiving a continuous tube feeding. Which of the following actions should the nurse take?

Correct Answer is D

Explanation

Client has a history of malnutrition, hyperlipidemia, and diabetes mellitus. The nurse is reviewing the client's medical record. Which of the following findings places the client at risk for delayed wound healing? Select all that apply.

Correct Answer is ["B","C","D"]

Explanation

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