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 C

Explanation

A. Encouraging feeding anything the child will eat might lead to poor nutrition. It's important to ensure a balanced diet.
B. Acknowledging the concern is valid, but the nurse should provide guidance rather than just expressing concern.
C. This response acknowledges the concern but reassures the parent that, if the child appears healthy, no immediate intervention is necessary, promoting a balanced approach.
D. Increasing calories and water without a specific reason or assessment may not address the underlying issue and is not the initial recommended intervention.

A. Purulent B. Serous C. Sanguineous D. Hyperemia

Correct Answer is C

Explanation

A) Purulent drainage is indicative of pus, which is associated with infection and is typically thick and yellow, green, or brown.
B) Serous drainage is clear, thin, and watery, and is generally considered normal in the early stages of healing.
C) Sanguineous drainage, which is the correct answer, refers to drainage that contains or is mixed with blood, making it appear blood-tinged, and is expected in a fresh incision or one that is healing by secondary intention.
D) Hyperemia is not a type of drainage but a term that describes increased blood flow to an area of the body, resulting in redness. Therefore, the nurse should document the finding as sanguineous, which accurately describes blood-tinged drainage.

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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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