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 A
Explanation
The correct answer is choice A. When assisting a client with a fractured hip to turn in bed, the nurse should plan to turn the client to the unaffected side, which is the right side. This helps to reduce pressure on the affected hip, minimize discomfort, and prevent further injury. Clients with hip fractures (choice B) can and should be turned with proper positioning and assistance. Keeping the client supine (choice C) for extended periods can lead to pressure ulcers, discomfort, and other complications. Repositioning the client to the left side (choice D) can cause additional pressure and discomfort on the affected hip. Therefore, turning the client to the right is the best option for repositioning a client with a fractured left hip who has been lying in the supine position for an extended period.
Correct Answer is C
Explanation
The correct answer is choice C. Signs of a wound infection include redness, warmth, and tenderness around the wound, as well as fever, chills, and malaise. The wound base may appear yellow, indicating the presence of pus, and may have a foul odor. Serous drainage is typically clear and does not indicate infection, while serosanguineous drainage may indicate a mild infection or normal healing process. An oral temperature of 101.5°F is elevated and may indicate an infection.
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