A nurse is assisting with the development of a plan of care for an older adult who is at risk for falls. Which of the following actions should the nurse contribute to the plan? (Select all that apply)
Keep the bed at a comfortable working height.
Administer a sedative at bedtime.
Keep a night light on in the client's room and bathroom.
Place the bedside table within the client's reach.
Lock the wheels on beds and wheelchairs during transfers.
Correct Answer : C,D,E
Keeping a night light on in the client's room and bathroom can help reduce the risk of falls by improving visibility and orientation at night. Placing the bedside table within the client's reach can help reduce the risk of falls by making it easier for the client to access necessary items without having to get up and move around. Locking the wheels on beds and wheelchairs during transfers can help reduce the risk of falls by providing stability and preventing unwanted movement.
a. Keeping the bed at a comfortable working height is important for the nurse's comfort and safety while providing care, but it does not directly reduce the risk of falls for the client.
b. Administering a sedative at bedtime may help the client sleep, but it can also increase the risk of falls by causing drowsiness and disorientation.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
The statement that clients in skin traction have more mobility than those in skeletal traction indicates that the newly licensed nurse understands these therapies. Skin traction is applied directly to the skin using splints, bandages, or adhesive tapes and is less invasive than skeletal traction³. Skeletal traction involves placing a pin, wire, or screw in the fractured bone and ataching weights to it to pull the bone into the correct position¹. Because skin traction is less invasive and does not involve inserting a pin into the bone, clients in skin traction have more mobility than those in skeletal traction.
a. Skeletal traction being better than skin traction for reducing a fracture is not necessarily true.
c. Skeletal traction having less risk for infection than skin traction is not true.
d. Clients in skin traction having more discomfort than those in skeletal traction is not necessarily true.
Correct Answer is D
Explanation
The nurse should expect to find edema of the toes first if the cast is too tight. A cast that is too tight can impede blood flow and cause swelling (edema) of the toes. If the nurse notices edema of the toes, they should report this finding to the provider and take appropriate action to prevent further complications.
Toes cool to touch may occur if the cast is too tight but this is not typically the first finding.
The inability to move toes may occur if the cast is too tight but this is not typically the first finding.
The pallor of the toes may occur if the cast is too tight but this is not typically the first finding.
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