A nurse is caring for a client who has a history of falling at their assisted living facility. The client is oriented
to person, place, and time and can follow directions. Which of the following actions should the nurse take to decrease the risk of another fall?
Apply restraints to the hands or wrists to keep the patient in bed.
Place a belt restraint on the client when they are sitting in a chair.
Keep the bed in lowest position with all four side rails up.
Educate the patient on using the call light and make sure the call light is within reach.
The Correct Answer is D
A. Apply restraints to the hands or wrists to keep the patient in bed: Restraints should only be used when absolutely necessary and as a last resort, and the client in this scenario is oriented and can follow instructions. Restraints can also increase the risk of injury, agitation, and further falls.
B. Place a belt restraint on the client when they are sitting in a chair: Belt restraints restrict movement and should only be used when other measures are insufficient to protect the client. Since the client is oriented and can follow directions, this intervention is not warranted and could cause harm.
C. Keep the bed in the lowest position with all four side rails up:
Incorrect. Raising all four side rails is considered a form of restraint and can increase the risk of injury. Clients may attempt to climb over the side rails, leading to falls. Keeping the bed in a low position is appropriate, but using all four side rails is not.
D. Educate the patient on using the call light and make sure the call light is within reach. This is the most appropriate action as the client is oriented and can follow directions. Educating the patient on how to use the call light and ensuring it is easily accessible encourages them to ask for assistance when needed, reducing the risk of falls.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
The correct answer is choice C. Call a code and begin resuscitating the client.
In a situation where a client is unresponsive, not breathing, and without a carotid pulse, the priority is to initiate emergency resuscitation measures. The nurse should call a code and begin resuscitating the client immediately, regardless of any prior conversations or wishes that the client may have expressed. If there is no DNR order on the client's chart, it is assumed that the client would want to be resuscitated in such an emergency situation. It is not appropriate for the nurse to make a decision based on a conversation that may or may not have taken place in the past without documentation or a valid DNR order. It is important to act quickly and follow emergency protocols to provide the best chance of survival for the client. After the resuscitation measures have been initiated, the healthcare team can reassess the situation and make decisions based on the client's condition and wishes, if known.
Correct Answer is D
Explanation
The correct answer is choice D, Jell-O, broth, apple juice. A clear liquid diet consists of fluids and foods that are clear and liquid at room temperature. These foods are easy to digest and leave no residue in the gastrointestinal tract. Examples include water, clear fruit juices, clear broths, tea, coffee without cream, and Jell-O.
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