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 B

Explanation

A. "I will move your joints to the point of mild pain":

This statement is incorrect. Passive range-of-motion exercises should not cause pain. The goal is to move the joints within their natural range of motion without causing discomfort or harm to the client. If pain occurs, the nurse should stop the movement and assess for any underlying issues.

B. "I will repeat these movements 3 to 5 times":

This is the correct statement. Passive range-of-motion exercises involve moving the client's joints through their range of motion without the client actively participating. Repeating the movements 3 to 5 times helps prevent joint stiffness and maintain flexibility without causing excessive strain or fatigue.

C. "These movements will be performed once per day":

This statement is less optimal. While performing passive range-of-motion exercises once a day may be beneficial, incorporating them into the client's routine more frequently, such as several times a day, can provide additional benefits in preventing joint contractures and maintaining joint function.

D. "I will move your joints quickly":

This statement is incorrect. Passive range-of-motion exercises should be performed slowly and gently. Moving the joints too quickly may cause discomfort or injury. The emphasis is on smooth, controlled movements to promote joint flexibility without causing harm.

A. Prepare the client for surgery. B. Obtain consent from the surgeon. C. Contact the facility's ethics committee for guidance. D. Keep the client stable until a family member arrives to give consent.

Correct Answer is A

Explanation

A. Prepare the client for surgery:
In emergency situations, if immediate intervention is required to save the client’s life or prevent significant harm, the principle of implied consent may apply. This means that if the client is unconscious and immediate treatment is necessary, healthcare providers may proceed with treatment under the assumption that the client would consent if able. However, this should be done in accordance with facility policies and legal guidelines.
B. Obtain consent from the surgeon:
The surgeon is not the appropriate person to obtain consent from in this situation. Informed consent should ideally come from the client or a legal surrogate decision-maker, depending on the circumstances. Surgeons are responsible for discussing the procedure with the patient or their authorized representative before surgery, but obtaining consent is not the nurse's role.
C. Contact the facility's ethics committee for guidance:
While the ethics committee may provide guidance in complex ethical situations, the immediate concern in this emergency situation is to address the client's life-threatening condition. The nurse should prioritize actions that ensure the client receives timely and necessary medical care.
D. Keep the client stable until a family member arrives to give consent:
While obtaining consent from a family member is ideal, waiting for consent can delay critical and time-sensitive interventions. In emergency situations, the priority is to provide necessary medical care promptly to stabilize the client. If there is no one available to give consent immediately, healthcare providers may proceed with necessary interventions to preserve life and limb.

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