A nurse is caring for a client who had a cerebrovascular accident and is at risk for falls. The nurse should recognize that which of the following is an appropriate safety precaution?

Monitor the client at least once every hr.

Assign the client to a private room.

Request a PRN prescription for restraints.

Keep four side rails up while the client is in bed.

Answer and Explanation

The Correct Answer is A

A.   Monitoring the client at least once every hour is an appropriate safety precaution to assess the client's condition and prevent falls.
B.   Assigning the client to a private room may not directly address the risk of falls and may not be necessary for fall prevention.
C.   Requesting a PRN prescription for restraints should not be the first line of defense for fall prevention and should only be considered when other interventions are ineffective or inappropriate.
D.   Keeping four side rails up while the client is in bed can be a restraint and may increase the risk of injury. It is not a recommended approach for fall prevention.

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Correct Answer is B

Explanation

A. The frequency of previous vital sign measurements may be important but is not the most critical information to communicate during a transfer.
B. The effectiveness of the last dose of pain medication is crucial information for the receiving facility to manage the client's pain appropriately.
C. The number of family members who have visited is important for emotional support but may not be the priority for the receiving facility.
D. The time of the client's last bath is relevant but may not be as critical as information related to pain management during the hand-off report.

A. Ciprofloxacin 200 mg IV q12h x 7 days B. Dx pyelonephritis C. Hourly 180 D. Acetaminophen 1000 mg PO QD

Correct Answer is B

Explanation

A. Ciprofloxacin 200 mg IV q12h x 7 days is a clear and acceptable prescription.
B. "Dx" is an unaccepted abbreviation; it is not appropriate for documentation and may lead to confusion.
C. "Hourly 180" is unclear and may need clarification; it could refer to an hourly measurement or a specific order, but it lacks clarity.
D. Acetaminophen 1000 mg PO QD is a clear and acceptable prescription.

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A nurse is caring for a client who had a cerebrovascular accident and is at risk for falls. The nurse should recognize that which of the following is an appropriate safety precaution?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is B

Explanation

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Correct Answer is B

Explanation

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