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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["1690"]
Explanation
To calculate the 8-hr fluid intake, convert all the measurements to milliliters (mL).
1 oz = 30 mL, so 6 oz of tea = 180 mL, 4 oz of apple juice = 120 mL, 8 oz of water = 240 mL, 3 oz of flavored gelatin = 90 mL, and 6 oz of broth = 180 mL.
Add up all the fluid intake from IV fluids and clear liquids: 880 + 180 + 120 + 240 + 90 + 180 = 1690 mL.
Round the answer to the nearest whole number: 1690 mL.
The nurse should document 1690 mL as the client's 8-hr fluid intake.
Correct Answer is D
Explanation
A. Showing the client how to use an artificial larynx is an important aspect of post-laryngectomy care, but determining the client's reading ability takes precedence as it will significantly impact communication options.
B. Arranging a support session is important for emotional support, but assessing the client's reading ability is more immediate in addressing communication needs.
C. Demonstrating the use of esophageal speech is relevant, but understanding the client's reading ability is a priority before exploring communication alternatives.
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